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SURGERY 


ITS  PRINCIPLES  AND  PRACTICE 


FOR  STUDENTS  AND  PRACTITIONERS 


BY 


ASTLEY  PASTfM  COOPER  ASHHURST,  A.B.,  M.D.,  F.A.C.S. 

ASSOCIATE    IN     SURGERY    IN    THE     UNIVERSITY     OF     PENNSYLVANIA,     SURGEON     TO     THE 

EPISCOPAL    HOSPITAL    AND    TO    THE    PHILADELPHIA    ORTHOPAEDIC    HOSPITAL    AND 

INFIRMARY    FOR    NERVOUS    DISEASES;    COLONEL,    MEDICAL    RESERVE 

CORPS,    U.    S.    ARMY 


SECOND  EDITION,   THOROUGHLY  REVISED 

WITH  14  COLORED  PLATES  AND  1 129  ILLUSTRATIONS  IN  THE  TEXT 
MOSTLY  ORIGINAL 


LEA  &   FEBIGER 

PHILADELPHIA   AND   NEW   YORK 
1920 


Copyright 

LEA  &   FEBIGER 

1920 


^3 

cr. 


TO 
RICHARD  H.  HARTE 

A    SURGEON    OF    WIDE    CLINICAL    EXPERIENCE 

AN    ABLE   TEACHER 

A    WISE   CONSULTANT 

A    SAFE   AND   SKILFUL    OPERATOR 

THIS   VOLUME 

IS    GRATEFULLY   DEDICATED 
BY    HIS   PUPIL,    ASSISTANT   AND   FRIEND 

THE  AUTHOR 


Copyright 

LEA  &   FEBIGER 

1920 


^3/ 


■^3 
CT 


TO 
RICHARD  H.  HARTE 

A    SURGEON    OF    WIDE    CLINICAL    EXPERIENCE 

AN    ABLE  TEACHER 

A    WISE   CONSULTANT 

A   SAFE   AND   SKILFUL   OPERATOR 

THIS   VOLUME 

IS    GRATEFULLY   DEDICATED 
BY   HIS   PUPIL,    ASSISTANT   AND   FRIEND 

THE  AUTHOR 


PREFACE  TO  THE  SECOND  EDITION. 


Compliance  with  the  request  of  the  publishers  for  the  preparation 
of  a  new  edition  of  this  work,  which  coincided  with  the  return  of  the 
author  from  service  with  the  American  Expeditionary  Forces,  has 
been  delayed  by  his  retention  for  some  months  in  the  military  service 
in  this  country,  as  well  as  by  disturbances  in  the  printing  trade. 

A  certain  amount  of  new  matter  has  been  introduced,  some  sections 
have  been  entirely  rewritten,  and  all  portions  of  the  volume  have 
been  thoroughly  revised  and  so  far  as  possible  brought  up-to-date. 
The  growing  importance  of  Reconstructive  Surgery  seemed  to  warrant 
assembling  in  one  place  paragraphs  which  in  the  first  edition  of  the 
work  were  dispersed  throughout  the  volume;  these  as  well  as  new 
material  derived  from  the  writer's  practice  are  presented  as  an  entirely 
new  chapter.  The  chapter  on  Gunshot  Wounds  has  been  entirely 
rewritten,  as  have  also  the  sections  in  other  chapters  dealing  with 
Shock,  Infected  Wounds,  Infections  of  the  Fingers  and  Hand,  Meta- 
static Arthritis,  Hydrocephalus,  Carcinoma  of  the  Tongue,  Empyema, 
Typhoid  Carriers  and  Surgery  of  the  Pancreas.  Seven  new  Colored 
Plates  and  over  one  hundred  new  illustrations  have  been  inserted, 
some  illustrations  used  in  the  first  edition  being  superseded,  and 
others  being  redrawn.  The  skillful  services  of  Mr.  Charles  F.  Bauer 
were  again  secured  for  this  purpose.  Most  of  the  new  skiagraphs  from, 
the  writer's  services  at  the  Episcopal  and  Orthopaedic  Hospitals  were 
made  by  Dr.  Ralph  S.  Bromer;  those  from  the  WTalter  Reed  General 
Hospital  were  made  by  Major  John  H.  Selby.  The  photographs 
illustrating  the  Carrel-Dakin  method  of  wound  treatment  are  from 
patients  at  the  latter  hospital  under  the  care  of  Lieut.-Col.  L.  J. 
Owen  and  First  Lieut.  Barron  Johns. 

It  is  to  be  regretted  that  these  additions  have  added  about  sixty 
pages  to  the  volume,  in  spite  of  continued  efforts  at  conciseness  of 
expression  and  omission  of  the  unessential. 

Thanks  are  due  the  Publishers  and  the  Printer  for  never-failing 
cooperation  and  aid  in  the  revision,  and  to  many  of  the  author's 

(v) 


vi  PREFACE  TO  THE  SECOND  EDITION 

friends  for  kindly   criticisms  and   suggestions.     All  readers  of  the 
volume  are  again  indebted  to  Dr.  A.  I).  Whiting  for  the  very  excellent 

Index. 

In  presenting  this  new  edition  of  his  work  to  the  Surgeons  and 
Students  of  Surgery  of  America,  the  writer  cannot  forbear  expressing 
his  gratitude  for  the  cordial  reception  accorded  to  the  volume  every- 
where on  its  first  appearance.  lie  ventures  to  hope  that  in  its  present 
form  it  may  continue  to  meet  with  the  approbation  of  his  colleagues. 

A.  P.  C.  A. 
1629  Spruce  Street,  Philadelphia,  1920. 


PREFACE  TO  THE  FIRST  EDITION. 


It  is  the  function  of  a  work  such  as  this  to  furnish  the  foundation 
on  which  a  knowledge  of  Surgery  is  to  be  built.  Didactic  and  clinical 
lectures,  papers  in  current  journals,  classical  monographs,  and  par- 
ticularly the  student's  clinical  work  and  the  surgeon's  daily  practice 
are  valuable  adjuncts,  but  unless  the  foundations  have  been  laid 
broad  and  deep,  no  useful  superstructure  can  be  erected. 

A  text-book  should  afford  a  true  perspective,  placing  the  various 
branches  of  study  in  their  proper  relative  position,  maintaining  their 
just  proportions,  and  providing  a  source  of  information  which  shall 
indicate  where  further  knowledge  is  to  be  gained.  A  student  seeks 
clear  and  accurate  statements,  and  desires  to  have  facts  set  definitely 
before  him.  If  the  present  volume  supplies  these  wants,  if  it  helps 
the  student  to  learn  surgery  and  proves  a  useful  reference  work  for 
the  practitioner,  it  will  have  fulfilled  its  purpose. 

Every  text-book,  however,  has  its  limitations.  At  best  it  can  but 
teach  the  student  to  know;  it  cannot  teach  him  to  do.  And  though 
knowledge  is  power,  much  practical  experience  in  laboratory,  dis- 
pensary and  hospital  wards  must  supplement  didactic  instruction. 
In  the  present  work  emphasis  is  placed  on  the  underlying  principles, 
and  pathogenesis,  diagnosis,  and  indications  for  treatment  have 
received  particular  attention.  Descriptions  of  operations,  however, 
have  not  been  slighted.  The  more  important  operations  have  been 
described  in  detail,  and  in  every  case  an  attempt  has  been  made  to 
present  clearly,  if  briefly,  at  least  one  method  of  operative  procedure. 
The  specialties  of  the  Eye,  the  Ear,  the  Nose,  and  the  Throat  naturally 
are  not  included;  and  Genito-urinary  Surgery,  Gynecology,  and 
Orthopedics  have  been  discussed  only  so  far  as  they  come  within 
the  province  of  the  general  surgeon. 

Neither  publishers  nor  author  have  spared  any  pains  in  the  endeavor 
to  furnish  a  text-book  on  Surgery  which  shall  be  acceptable  to  the 
profession.  The  illustrations,  with  very  few  exceptions,  are  entirely 
original,  and  are  reproductions  of  photographs  or  sketches  made  by 
the  writer  in  his  various  services,  especially  at  the  Episcopal  Hospital 
of  Philadelphia.  To  his  long  association  with  this  Hospital  he  owes 
unsurpassed  opportunities  for  clinical  work;  as  well  as  to  his  associa- 
tion with  the  Orthopaedic  Hospital,  and  to  his  former  services  at  the 

(vii) 


viii  PREFACE   TO   THE  FIRST  EDITION 

Pennsylvania,  the  Children's,  and  the  German  Hospitals.  Most  of 
the  skiagraphs  are  derived  from  the  Episcopal  Hospital,  and  were 
made  by  Dr.  Thomas  S.  Stewart  or  his  assistant,  Dr.  A.  R.  Wilkinson. 
Those  from  the  Orthopaedic  Hospital  were  made  by  Dr.  Wm.  Van 
Korb.  The  illustrations  of  operative  technique  are  based  largely  mi 
work  done  in  the  writer's  Laboratory  of  Operative  Surgery  in  the 
University  of  Pennsylvania.  The  credit  for  converting  the  author's 
diagrams  and  photographs  into  admirable  illustrations  is  due  to 
Mr.  Charles  F.  Bauer. 

Much  help  has  been  derived  from  other  text-books  and  systems  of 
surgery.  First  and  foremost  among  these  must  be  mentioned  the 
Principles  and  Practice  of  Surgery  of  John  Ashhurst,  Jr.  The  indebted- 
ness of  the  writer  of  the  present  work  to  that  volume  can  be  appre- 
ciated best  by  those  who,  like  himself,  acquired  the  basis  of  their 
surgical  education  from  its  pages.  Every  other  source  of  information 
has  been  studiously  sought;  and,  thanks  to  the  facilities  afforded  by 
the  Library  of  the  College  of  Physicians  of  Philadelphia,  this  laborious 
task  has  been  rendered  comparatively  easy.  It  wTas  thought  inadvis- 
able to  cumber  the  text  with  bibliographical  references,  but  the  dates 
of  publication  of  authoritative  contributions,  whether  recent  or  of 
historical  interest,  have  been  indicated,  and  it  is  believed  that  by  this 
means  the  original  references  may  be  more  easily  found  in  the  Index 
Medicus  or  in  the  Index  Catalogue  of  the  Surgeon-General's  Library, 
U.  S.  Army.  The  author  is  particularly  indebted  to  the  writings 
of  Deaver  on  abdominal  and  prostatic  surgery;  and  free  citations 
have  been  made  from  the  volumes  published  by  this  brilliant  surgeon 
in  collaboration  with  the  writer. 

The  text  of  the  present  volume  has  received  the  criticisms  of  several 
of  the  author's  friends.  Dr.  Henry  Winsor  and  Dr.  Penn-Gaskell 
Skillern,  Jr.,  have  devoted  themselves  to  this  work  most  unselfishly, 
and  have  offered  many  valuable  corrections  and  suggestions.  -Dr. 
G.  G.  Davis  and  Dr.  Frank  D.  Dickson  have  kindly  reviewed  the 
chapters  on  Orthopedic  Surgery  and  on  Diseases  of  the  Joints.  Dr. 
A.  D.  Whiting  has  assisted  in  reading  the  proof-sheets,  and  has  made 
the  index.  A.  P.  C.  A. 

811  Spruce  Street,  Philadelphia,  1914. 


CONTENTS. 


GENERAL  SURGERY 

CHAPTER  I 
Inflammation 17 

CHAPTER  II 
Diseases  Resulting  from  Inflammation 46 

CHAPTER  III 
Surgical  Infections 74 

CHAPTER  IV 
Tumors 101 

CHAPTER  V 

Surgical  Technique 135 

CHAPTER  VI 
Injuries  and  their  Effects 159 

CHAPTER  VII 
Gunshot  Wounds 190 

CHAPTER  VIII 
Amputations 212 

CHAPTER  IX 

Reconstructive  Surgery 236 

(ix) 


x  CONTENTS 

SYSTEMIC  SURGERY 

CHAPTER  X 

Surgery  of  the  Blood-vascular  System 259 

CHAPTER  XI 

Surgery  of  the  Skin,  Burs^e,  Lymphatics,  Muscles,  Tendons,  and 

Nerves 290 

CHAPTER  XII 
Fractures 327 

CHAPTER  XIII 
Injuries  of  Joints 421 

CHAPTER  XIV 
Diseases  of  Bone 454 

CHAPTER  XV 
Diseases  of  Joints 492 

CHAPTER  XVI 
Orthopedic  Surgery 546 

REGIONAL  SURGERY 

CHAPTER  XVII 
Surgery  of  the  Head 595 

CHAPTER  XVIII 
Surgery  of  the  Spine 637 

CHAPTER  XIX 
Surgery  of  the  Face,  Mouth,  and  Neck 666 

CHAPTER  XX 
Surgery  of  the  Breast,  Chest  Wall,  Lungs,  and  Diaphragm     .      .     .       748 


CONTENTS  xi 

CHAPTER  XXI 
Hernia 805 

CHAPTER  XXII 

Abdominal   Surgery   in   General,    and   Injuries   of   the   Abdominal 
Viscera 853 

CHAPTER  XXIII 

Surgery  of  the  Gastro-intestinal  Tract 900 

CHAPTER  XXIV 

Surgery  of  the  Gall-bladder,  Liver,  Pancreas,  and  Spleen      .      .      .       974 

CHAPTER  XXV 
Surgery  of  the  Bladder  and  Kidneys 1013 

CHAPTER  XXVI 

Venereal  Diseases 1044 

CHAPTER  XXVII 

Surgery  of  the  Urethra  and  Prostate 1070 

CHAPTER  XXVIII 
Surgery  of  the  Male  Genital  Organs 1099 

CHAPTER  XXIX 
Surgery  of  the  Female  Genitals 1121 


SURGERY:  ITS  PRINCIPLES  AND  PRACTICE. 


The  word  Surgery  (old  English  Chirurgery)  is  derived  from  two 
Greek  words,  %tlp  and  epfov,  signifying  respectively  hand  and  work; 
as  distinguished  from  the  work  of  the  physician,  surgery  was  there- 
fore formerly  confined  to  such  mechanical  procedures  as  were  carried 
out  by  the  surgeon  under  the  direction  of  the  physician.  Such  was 
the  position  of  the  surgeon  in  the  middle  ages;  but,  since  the  time  of 
Ambroise  Pare  (1509-1590),  who  is  thus  justly  styled  the  Father  of 
Modern  Surgery,  the  Science  and  Art  of  Surgery  have  advanced  step 
by  step  toward  such  a  point  of  perfection  as  long  since  to  have  entitled 
them  to  equal  rank  with  Medicine.  And  though  the  highest  func- 
tions of  surgery  still  remain  mechanical  in  nature,  it  is  no  longer  the 
physician  who  plans  and  directs  the  mechanical  treatment,  but  the 
surgeon  himself  who  selects  the  patient,  devises  the  operation,  and 
determines  at  what  stage  of  the  malady  surgical  measures  shall  be 
employed. 

Underlying  all  disease,  and  therefore  necessary  to  an  understand- 
ing of  disease  processes,  surgeons  encounter  a  pathological  state 
which  constitutes  the  process  by  which  the  bodily  tissues  react  to 
injury.  If  the  injury  be  very  severe,  immediate  death  of  the  part 
may  ensue;  and  there  will  then  be,  in  that  part,  no  reaction  to  the 
injury.  At  the  very  outset  of  the  study  of  surgery,  it  is  proper  to 
discuss  at  some  length  the  reaction  which  takes  place  when  the  tissues 
are  injured,  because  only  when  the  underlying  principles  of  disease 
and  injury  have  been  thoroughly  mastered,  can  it  be  hoped  to  study 
with  profit  the  special  affections  which  subsequently  will  be  discussed. 


CHAPTER  I. 

INFLAMMATION. 

The  process  by  which  the  tissues  react  to  an  irritant  is  known  as 

Inflammation.     The  student  must  therefore  learn  what  are  the  usual 

irritants  which  produce  these  changes;  he  must  study  the  changes 

themselves,  and  their  results;  he  must  familiarize  himself  with  the 

2  (17) 


IS  INFLAMMATION 

subjective  and  objective  symptoms  due  to  these  tissue  changes;  and 
he  must  finally  learn  how  to  relieve  the  patient  of  his  suffering.  It 
therefore  becomes  necessary  to  discuss  the  causes,  the  pathology,  the 
symptoms,  and  the  treatment  of  inflammation. 

Causes. — The  predisposing  causes  of  inflammation  are  those  which 
render  the  patient  especially  liable  to  the  action  of  irritants,  which 
are  the  exciting  causes.  Any  constitutional  state,  therefore,  which 
lowers  the  resistance  to  disease  or  injury  will  act  as  a  predisposing 
cause.  Age,  especially  the  extremes  of  life,  influences  the  develop- 
ment of  inflammation  in  this  way.  Occupation  and  habits  also  have 
an  undoubted  influence,  by  undermining  or  by  strengthening  the  con- 
stitution. Past  or  present  diseases  may  very  seriously  modify  the 
patient's  resistance  to  the  exciting  causes  of  inflammation. 

In  general  it  may  be  admitted  that  the  exciting  or  determining 
causes  of  inflammation  are  either  mechanical  or  chemical,  using  these 
terms  in  their  broadest  sense,  and  including  in  the  latter  all  causes 
(thermal,  electrical,  radio-active,  infective)  which  are  not  distinctly 
mechanical  in  their  action.  But  while  it  is  expedient  to  acknowl- 
edge that  the  process  of  repair  which  occurs  after  such  mechanical 
injuries  as  contusions,  fractures,  aseptic  wounds,  and  the-  like  is  in 
very  fact  an  inflammatory  process,  it  is  nevertheless  proper  to  recog- 
nize the  fact  that  the  vast  majority  of  inflammatory  affections  are 
directly  due  to  chemical  irritants  produced  in  the  tissues  by  micro- 
organisms, especially  bacteria.  Indeed,  it  is  seldom  susceptible  of 
satisfactory  proof  that  bacteria  are  entirely  absent  in  the  class 
of  injuries  first  mentioned;  for  it  is  probable  that  all  patients,  and 
even  persons  in  good  health,  have  somewhere  in  their  system 
certain  bacteria  which,  being  carried  by  the  blood  or  lymph  currents, 
eventually  will  reach  the  region  of  damaged  tissue,  and  will  there  be 
enabled  to  prosecute  their  nefarious  work  to  better  advantage  than 
where  there  exists  no  locus  minoris  resistentiw. 

Foreign  bodies  were  cited  formerly  as  examples  of  purely  mechani- 
cal causes  of  inflammation;  but  unless  it  can  be  proved  that  the 
foreign  body  is  aseptic,  and  that  the  part  of  the  body  where  it  lodges 
(eye,  skin)  is  also  free  from  bacteria,  it  is  proper  to  assume  even  in 
such  cases  that  the  resulting  inflammatory  reaction,  if  noticeable, 
is  due  as  much  to  bacteria  as  to  the  presence  of  a  foreign  body. 
Indeed,  we  know  that  many  sterile  foreign  bodies  (ligatures,  sutures) 
constantly  remain  in  the  tissues  after  aseptic  operations,  and  are 
productive  of  no  manifest  inflammatory  reaction.  Likewise  calculi, 
formed  in  the  internal  organs,  if  sterile  themselves,  may  be  productive 
of  only  trivial  discomfort  until  bacterial  infection  occurs  in  their 
containing  viscus. 

The  bacteria  which  surgeons  most  frequently  encounter  as  causes  of 
inflammation  are  the  Micrococcus  pyogenes  (Staphylococcus) ;  Strepto- 
coccus pyogenes;  Bacillus  coli  communis;  Gonococcus;  Bacillus  pyo- 
eyaneus;  Pneumococcus;  Bacillus  typhosus;  Bacillus  tuberculosis; 
Bacillus  tetani;  Bacillus  mallei;  Bacillus  anthracis;  Bacillus  aerogenes 


PATHOLOGY  19 

capsulatus,  etc.  These  microorganisms  are  known  as  Pathogenic 
Bacteria,  because  they  are  themselves  the  causes  of  disease;  they  take 
up  their  abode  and  thrive  in  living  tissues,  which  they  use  as  pabulum. 
They  are  to  be  distinguished  from  Saprophytic  Bacteria,  which  exist 
only  in  dead  tissues;  these  can  be  regarded  as  causes  of  disease  only 
in  a  more  or  less  indirect  manner,  because  it  is  necessary  that  other 
agents,  chiefly  the  pathogenic  bacteria,  shall  have  previously  brought 
about  the  death  of  the  tissues. 

In  addition  to  bacteria,  certain  other  forms  of  microorganismal 
life  must  be  recognized  as  occasional  causes  of  the  inflammatory 
process  in  man.  Among  these  are  certain  animal  parasites,  certain 
Yeasts,  or  Blastomycetes,  and  certain  Moulds,  or  Hyphomycetes. 
Among  the  more  important  of  the  latter  may  be  mentioned  Oidium 
Albicans,  which  causes  Thrush;  the  various  forms  of  fungi,  which  cause 
the  skin  lesions  of  favus,  tinea,  etc.;  and  the  Ray  Fungus,  which 
causes  Actinomycosis. 

The  chemical  substances  produced  by  pathogenic  bacteria,  as  a 
result  of  their  action  upon  the  tissues,  are  described  by  the  general 
name  toxins  (Roux  and  Yersin,  1888);  endo-toxins  are  those  substances 
formed  in  the  bodies  of  dead  or  dying  bacteria.  Both  toxins  and 
endo-toxins  act  as  chemical  irritants,  and  it  is  these  products  of 
bacteria,  and  not  the  bacteria  themselves,  which  are  regarded  as 
causes  of  inflammation.  The  products  of  pathogenic  bacteria  are 
albuminoid  in  nature;  those  elaborated  by  saprophytic  bacteria  are 
alkaloidal,  and  go  by  the  general  name  ptomains.  The  action  of 
'thermal,  electrical,  and  radio-active  agents  as  causes  of  inflammation 
will  be  discussed  under  separate  sections  in  other  portions  of  this 
vokime. 

Pathology. — The  pathology  of  the  inflammatory  process  is  the  same 
in  kind,  though  varying  somewhat  in  its  characteristics,  according 
to  the  irritant  cause,  and  to  the  particular  tissue  affected.  Certain 
bacteria  produce  a  reaction  so  peculiarly  characteristic  that  surgeons 
have  dignified  the  resulting  processes  by  erecting  them  into  diseases 
to  which  special  names  are  applied.  Such  are  Tuberculosis,  Syphilis, 
Anthrax,  Glanders,  and  other  affections  which  are  grouped  together 
as  the  Infectious  Granulomas.  These  diseases  therefore  are  described 
in  a  separate  chapter  (Chapter  III);  in  the  present  chapter  will  be 
described  only  those  changes  which  are  usually  understood  when  the 
term  inflammation  is  used.  Even  among  the  bacteria  which  cause 
the  changes  universally  recognized  as  inflammation,  the  form  of 
reaction  varies  considerably,  so  that  it  is  sometimes  possible  to  assert 
without  microscopical  or  bacteriological  examination  that  the  inflam- 
mation is  due  to  one  variety  of  bacteria,  not  to  another.  It  is  also 
sometimes  possible  for  the  experienced  observer  to  assert  that  the 
same  variety  of  microorganism  is  the  cause  of  quite  divergent  types 
of  inflammation  in  different  organs  or  tissues  of  the  body. 

If  one  were  to  watch  under  the  microscope  the  changes  which  occur 
in  a  part  on  which  an  irritant  is  acting,  he  would  obtain  a  very  accurate 


1M) 


INFLAMMATION 


idea  of  the  process  of  inflammation.  This  may  be  done  in  the  patho- 
logical laboratory;  but  great  experience  is  required  properly  to  inter- 
pret what  is  seen;  and  for  practical  purposes  it  is  better  to  study,  at 
leisure,  a  series  of  illustrations  of  an  inflamed  area,  made  at  various 
stages  of  the  process. 

Studying  first  the  vascular  tissues,  it  is  noted  that  the  capillaries 
dilate,  those  which  before  were  too  small  to  allow  the  entrance  of  the 
cellular  elements  of  the  blood  now  increase  in  diameter,  and  it  is  even 
possible  that  new  vascular  channels  may  be  formed.  More  blood 
comes  to  the  part,  more  blood  passes  through  it,  and  more  blood 
leaves  it,  than  in  the  normal  state.  This  change  is  spoken  of  as  active 
hyperemia  {determination,  fluxion  of  blood),  to  distinguish  it  from 
passive  hyperemia  or  congestion;  in  this  latter  state,  although  there  is 
more  blood  actually  in  the  part  than  in  the  normal  state,  yet  the  blood 
is  more  or  less  stagnated  in  the  part,  and  does  not  leave  it,  owing  to 


ffHf 


Fig.  1 . — Subcutaneous  tissue  some  distance  above  dead  part  in  a  case  of  spreading 
gangrene.  Note  stasis,  margination,  and  migration.  Three  veins  packed  with  leuko- 
cytes (I),  which  are  escaping  freely.  Around  the  artery  (below)  there  are  none.  Out- 
side the  vessels  many  larger  cells  are  seen.      X  200.     (Green.) 


venous  obstruction,  which  is  the  prime  cause  of  the  congestion.  In 
inflammation,  although  no  cause  of  venous  obstruction  exists,  the 
active  hyperemia  above  described  soon  undergoes  a  change,  so  that 
the  picture  more  nearly  resembles  that  seen  in  congestion.  The 
blood  moves  more  slowly  through  the  vessels,  the  blood  cells,  espe- 
cially the  leukocytes,  tend  to  cling  to  the  vessel  walls  (margination), 
and  eventually  some  of  the  leukocytes  escape  through  spaces  between 
the  endothelial  cells  lining  the  capillaries  by  a  process  known  as  m  igra- 
tion  (J.  F.  Cohnheim,  1867).     In  some  cases  of  severe  inflammation 


PATHOLOGY  21 

the  erythrocytes  may  he  forced  out  of  the  vessels  as  well  (diapedesis). 
In  the  case  of  the  leukocytes,  however,  the  process  is  active  (migration), 
and  is  not  a  mere  matter  of  filtration  by  the  vis  a  tergo.  It  is  held 
by  some  that  the  erythrocytes  escape  from  the  vessels  in  the  wake 
of  the  leukocytes,  being  sucked  out  by  the  currents  produced  in 
the  blood-plasma  by  the  migration  of  the  white  blood  cells.  In 
the  process  of  migration  of  the  leukocytes,  first  a  portion  of  the 
cytoplasm,  projected  as  a  pseudopod,  emerges  through  the  vascular 
wall;  then  more  of  the  cell  body  follows;  and  finally  the  portion  still 
remaining  within  the  bloodvessel  flows  out  into  that  portion  which 
has  already  migrated.  It  has  been  noted  by  Councilman  that  the 
portion  of  the  cell  to  migrate  first  always  contains  the  nucleus;  and 
it  has  been  suggested  by  Adami  and  others  that  there  exists  some 
relationship  between  "the  labile,  broken-up  character"  of  the  nucleus 
of  polymorphonuclear  leukocytes  (perhaps  karyokinetic  figures)  and 
their  function  of  migration  through  the  vessel  walls. 

It  is  further  evident  that  some  of  the  plasma  of  the  blood  has 
escaped  from  the  vascular  channels  and  is  infiltrating  the  perivas- 
cular connective  tissue;  for  the  connective  tissue  cells  may  be  seen 
to  swell  up  and  become  engorged  with  foreign  fluid.  This  fluid  exudate, 
however,  is  not  unaltered  blood-plasma;  it  contains  a  higher  per- 
centage of  proteids,  and  its  specific  gravity  is  higher;  it  also  coagu- 
lates more  quickly.  Moreover,  as  will  be  pointed  out  presently,  it 
is  extremely  rich  in  bactericidal  and  antitoxic  substances.  The 
increase  of  serum  in  an  inflamed  part  is  frequently  very  apparent 
macroscopically  when  incisions  are  made  to  relieve  tension,  especially 
in  the  loose  subcutaneous  tissues;  and  when  inflammation  occurs  on 
free  surfaces,  as  the  peritoneum  or  the  mucous  membranes,  or  just 
beneath  the  cuticle,  as  in  blisters,  the  outpouring  of  this  fluid  exudate 
is  very  evident.  Its  quantity  and  quality  are  also  influenced  by  the 
variety  of  bacteria  present. 

Looking  a  little  later  at  the  inflamed  area,  the  first  thing  to  be  noted 
is  that  there  has  accumulated  in  the  perivascular  tissues  an  immense 
aggregation  of  small  round  cells.  These  cells  accumulate  in  response 
to  an  influence  of  chemical  nature  exerted  upon  them  by  the  bacteria 
or  other  irritant;  this  influence  is  known  as  ehemotactie  action 
(Pfeft'er,  18881),  and  because  the  cells  are  drawn  toward  the  acting 
body,  we  speak  of  it  as  positive  chemotaxis,  in  contradistinction  to 
negative  chemotaxis,  which  term  is  used  to  describe  the  repelling 
action  of  certain  cells  or  microorganisms.  The  endothelial  cells  lining 
the  bloodvessel  walls,  under  the  influence  of  the  positive  ehemotactie 
action  of  the  irritant,  may  be  seen  to  swell  up  and  bulge  into  the  lumen 
of  the  vessels.  In  this  manner  they  seem  to  become  possessed  of  agglu- 
tinative characteristics,  which  aid  in  slowing  the  blood  stream  and 
in  producing  the  margination  of  the  leukocytes  already  described. 

1  According  to  the  late  Prof.  Ashhurst,  the  germ  of  the  idea  of  chemotaxis  is 
to  be  found  in  the  writings  of  Haller. 


22  INFLAMMATION 

It  is  not  impossible  that,  by  their  change  of  form,  these  endothelial 

cells  may  render  the  vessel  walls  more  readily  permeable  to  the 
leukocytes. 

The  origin  of  this  vast  aggregation  of  round  cells  next  engages 
our  attention.  By  reference  to  our  previous  study  of  the  changes 
in  the  vascular  tissues,  it  is  quite  evident  that  large  numbers  of  the 
round  cells  found  in  the  inflamed  tissues  have  been  derived  from  the 
leukocytes  of  the  blood  by  migration.  But  even  in  tissues  without 
bloodvessels,  such  as  the  cornea,  a  similar  aggregation  of  cells  occurs 
in  inflammation;  so  that  it  is  manifest  that  much  of  the  round-cell 
infiltration  is  derived  from  other  sources  than  the  bloodvessels. 
These  other  sources  are  the  lymph  cells,  which  exist  in  the  perivas- 
cular tissues  within  the  lymph  spaces  and  lymph  capillaries;  and  the 
fixed  connective  tissue  cells,  which  as  the  result  of  a  retrograde 
metamorphosis  come  again  to  resemble  the  less  highly  developed 
lymphocytes  (Strieker,  1881).  Strieker  also  believed  that  the  inter- 
cellular connective  tissues  could,  under  the  influence  of  the  inflam- 
matory process,  revert  again  to  the  embryonal  cells  from  which  they 
were  first  derived.  Whether  Strieker's  views  should  be  accepted  or 
not,  is  still  perhaps  open  to  discussion;  but  pathologists  think  it  much 
more  certain  at  present  that  a  large  proportion  of  the  round-cell  aggre- 
gation is  derived  from  the  endothelial  cells  lining  the  lymph  spaces 
of  the  perivascular  tissues.  Indeed,  according  to  some  modern  his- 
tologists  there  are  no  such  structures  as  those  formerly  described 
as  the  fixed  connective-tissue  cells;  for  they  hold  that  the  only  cells 
found  in  the  tissues,  besides  the  lymphocytes  and  the  wandering  leuko- 
cytes, are  these  very  endothelial  cells,  and  that  the  spaces  (hypothetical 
or  real)  between  them  are  to  be  regarded  as  lymph  channels. 

In  regard  to  the  origin  of  the  lymphocytes,  Warthin  (1906)  follows 
Ribbert  in  teaching  that  they  are  in  great  part  derived  from  rudi- 
mentary lymph  nodes  scattered  through  the  tissues. 

The  great  number  of  cells  which  infiltrate  the  tissues  at  this  stage 
of  the  inflammatory  process,  must  not  be  regarded  as  a  mere  aggre- 
gation of  previously  existing  cells.  It  is  probable  that  all  the  cells 
multiply  by  continual  division  and  subdivision  under  the  stimulus  of 
inflammation,  and  that  the  number  of  cells  in  the  part  is  thus  actually 
as  well  as  relatively  increased.  This  fact  is  evident  from  the  mitoses 
which  may  be  seen  in  an  inflamed  area  under  the  microscope. 

Thus  it  is  that  we  find  three  main  types  of  cells  composing  this 
cellular  infiltrate:  (1)  the  emigrated  leukocytes,  which  are  chiefly  poly- 
morphonuclear neutrophiles ;  in  the  early  stages  of  inflammation  there 
may  be  a  relative  increase  of  eosinophile  cells;  (2)  the  lymphocytes, 
which  seldom  accumulate  in  great  numbers  until  the  inflammation 
has  existed  for  some  days;  and  (3)  cells  derived  from  the  fixed  con- 
nective tissue  cells  or  from  the  endothelial  cells,  or  from  both.  These 
last  named  cells  are  conveniently  classified  by  Adami  as  fibroblasts 
and  polyblasts,  the  latter  term,  first  employed  by  Maximow,  being 
intended  to  signify  that  they  are  immature  types  of  various  kinds  of 


PATHOLOGY  23 

fully  formed  cells;  while  the  name  fibroblast  is  still  used  to  describe 
that  form  of  immature  connective-tissue  cell  on  which  the  subsequent 
process  of  repair  chiefly  depends. 

When  we  come  next  to  inquire  into  the  object  of  this  round-cell 
infiltration,  we  learn  by  observation  that  a  veritable  warfare  is  going 
on  between  the  bacteria  and  these  cells.  We  observe,  for  instance, 
that  many  of  the  cells  (leukocytes  and  endothelial  cells  in  particular) 
have,  as  it  were,  swallowed  some  of  the  bacteria;  for  we  see  such 
cells  with  one,  two,  three,  or  more  bacteria  in  their  interior.  We 
may  infer  that  some  of  the  bacteria  are  being  killed,  both  from  the 
gradual  diminution  in  their  total  number,  as  well  as  because  the  indi- 
vidual bacteria  no  longer  stain  so  wrell  as  at  first;  and  we  also  per- 
ceive that  many  of  the  body  cells  succumb,  because  their  nuclei  swell 
up,  their  protoplasm  becomes  cloudy,  they  fail  to  stain,  and  finally 
disintegrate  and  disappear,  while  the  triumphant  bacteria  attack 
other  cells.  This  process,  by  which  the  cells  devour  the  bacteria,  is 
known  as  phagocytosis  (Metchnikoff,  1893),  and  the  cells  wdiich  thus 
act  are  called  phagocytes. 

Moreover,  in  addition  to  the  defence  thus  provided  by  the  cellular 
elements  called  into  action  by  the  irritants  causing  inflammation, 
there  exist  in  the  body  fluids  certain  substances  (anti-bodies)  which 
act  as  very  important  aids  in  the  defence.  In  the  normal  blood- 
plasma  exist  certain  chemical  substances  termed  opsonins  (Wright 
and  Douglas,  1903),  because  they  act  as  caterers  for  the  phagocytes, 
by  preparing  the  bacteria  for  destruction.  Thus  it  has  been  found 
that  though  white  blood  cells  are  active  phagocytes  while  still  sur- 
rounded by  blood  plasma,  they  are  absolutely  indifferent  to  bacteria 
if  deprived  of  plasma.  In  the  fluid  exudate  which  is  produced  during 
the  inflammatory  process  there  are  also  chemical  substances,  known 
as  bacteriolysins  (Nuttall,  1888),  which  are  extremely  destructive  to 
these  causes  of  inflammation;  these  bacteriolysins  are  classified  as 
alexins  (Buchner,  1890),  which  destroy  the  bacteria,  and  antitoxins 
(Behring,  1890),  which  neutralize  the  bacterial  toxins.  It  is  probable 
that  they  are  both  produced  by  disintegration  of  leukocytes.  These 
inflammatory  exudates  have  a  specific  gravity  of  1018  or  higher,  and 
contain  at  least  4  per  cent,  of  albumin;  they  may  be  distinguished 
thus  from  exudates  due  to  venous  stasis,  and  from  those  caused  by 
hydremic  conditions,  the  fluid  in  the  latter  instances  having  a  much 
lower  specific  gravity,  and  containing  less  albumin. 

The  process  of  inflammation,  as  thus  far  described,  comprises 
clinically  what  has  been  termed  the  first  stage  of  inflammation,  or  the 
stage  of  temporary  hypertrophy.  If  at  this  stage  of  the  process  the 
invading  microbes  are  vanquished,  the  parts  return  to  their  normal 
condition  (resolution)  without  passing  through  the  subsequent  stages 
of  inflammation.  If,  on  the  other  hand,  the  strife  is  prolonged,  the 
fluid  exudate  and  the  cellular  infiltrate  increase  in  quantity,  and  the 
product  of  the  second  stage  of  inflammation,  known  as  inflammatory 
lymph,  is  formed  (lymphization,  lymphogenesis.) 


24  INFLAMMATION 

Inflammatory  lymph  (Hunter,  1794)  is  a  semi-solid,  gelatinous 
substance,  grayish  white  or  slightly  yellowish  in  tint.  Though  found 
at  least  for  a  short  time  in  every  ease  of  inflammation  which  extends 
beyond  the  first  stage,  it  is  best  observed  in  peritoneal  infections, 
and  in  iritis,  in  both  of  which  instances  the  inflammatory  exudate 
occurs  on  a  free  surface.  The  false  membrane  of  diphtheritic  inflam- 
mation is  another  instance  of  lymph  formation.  Lymph  owes  its 
semi-solid,  plastic  character  to  the  fibrin  it  contains.  The  cellular 
elements  are  not  usually  very  numerous  in  the  early  stages  of  its 
formation,  when  the  exudate  is  still  "serous,"  but  as  the  quantity  of 
cells  increases,  fibrin  ferment  is  formed  by  the  destruction  of  some  of 
their  number,  and  this  fibrin  ferment  acting  upon  the  fibrinogen  and 
certain  calcium  salts  already  present  in  the  exudate,  eventually  forms 
fibrin.  Certain  infectious  agents  call  forth  an  abundant  exudation 
of  inflammatory  lymph;  while  others  are  characterized  rather  by  the 
excessive  round-cell  infiltration  produced.  For  example,  peritonitis 
due  to  the  typhoid  bacillus  is  characterized  by  profuse  serous 
exudate;  when  caused  by  the  streptococcus,  or  the  colon  bacullus, 
the  exudate  contains  a  much  larger  proportion  of  cellular  elements, 
and  therefore  more  closely  resembles  typical  inflammatory  lymph. 
Moreover,  fluid  exudation  is  more  abundant  on  surfaces,  and  in 
the  loosely  built  cellular  tissues,  than  in  denser  structures  such  as 
bone. 

Lymph  serves  a  useful  purpose  in  more  ways  than  one,  for  not  only 
does  it  enmesh  the  microorganisms  and  thus  prevent  their  diffusion 
in  the  tissues,  but  it  also  actively  destroys  them  and  their  products 
by  means  of  the  bacteriolysins  already  described.  It  also  prevents 
absorption  of  the  microorganisms  by  protecting  denuded  endothelial 
surfaces.  It  is,  therefore,  to  be  regarded  as  a  valuable  defence  of  the 
body  against  infection,  and  not  as  a  noxious  product  to  be  removed 
by  the  surgeon. 

Lymph  may  be  absorbed,  may  become  organized,  may  become 
converted  into  pus,  or  may  undergo  other  forms  of  degeneration 
(caseous,  calcareous,  etc.).  If  the  lymph  is  absorbed,  its  cellular 
elements  pass  away  again  into  the  neighboring  blood  and  lymph 
streams,  or  remain  as  fibroblasts  to  produce  new  connective  tissue  in 
the  area  of  inflammation.  Where  the  process  of  inflammation  is 
attended  by  coincident  productive  and  absorptive  changes,  in  approxi- 
mately equal  degree,  the  condition  is  described  as  interstitial  absorp- 
tion. This  condition  is  seen  particularly  in  some  forms  of  osteitis. 
In  the  process  of  organization,  which  will  be  described  more  particu- 
larly in  the  section  on  Repair  (p.  29),  these  fibroblasts  pass  through 
various  stages  until  adult  connective  tissue  is  formed.  It  is  very 
unusual,  however,  for  complete  regeneration  (restitutio  ad  integrum) 
to  take  place;  almost  ahvays  some  of  the  cells  remain  in  an  immature 
state,  while  others  are  converted  into  scar  tissue.  In  certain  specialized 
forms  of  inflammation,  lymph  undergoes  various  forms  of  degeneration, 
as  the  caseous  or  calcareous,  in  tuberculosis;  but  in  all  cases  in  which 


PATHOLOGY 


25 


the  inflammatory  process  continues,  lymph  is  eventually  converted 
into  pus  (suppuration,  pyogenesis). 

Pus  may  be  defined  as  the  product  of  the  third  stage  of  inflamma- 
tion.    By  giving  a  broad  definition  such  as  this,  we  are  permitted, 


Fig.  2. — Miliary  abscess  in  a  case  of  septic  embolism  of  the  kidney:  a,  leukocytes 
advancing  toward  and  surrounding  b,  a  mass  of  cocci,  in  whose  neighborhood  all  trace 
of  a  structure  has  disappeared;  c,  renal  epithelium  too  damaged  by  bacterial  products 
to  take  the  stain;  d,  kidney  tissue  staining  normally;  e,  vein  from  which  leukocytes  are 
making  their  way  to  the  commencing  abscess.      X  100.      (Green.) 

as  is  pathologically  proper,  to  include  under  the  term  pus,  not  only 
the  healthy,  laudable  pus  which  the  older  surgeons  were  so  delighted 
to  behold,  as  an  expression  of  adequate  reaction  on  the  part  of  the 
patient's  tissues;  but  we  may  also  embrace,  under  the  term  pus,  the 


L'li  i\i'L.\\tu.\rio\ 

products  of  tuberculous,  syphilitic,  and  similar  processes  which,  as 
Adami  points  out,  "are  identical  with  the  tissue  dissolution  that 
occurs  in  acute  abscess." 

Pus,  when  examined  under  the  microscope,  is  seen  to  be  composed 
of  cells  and  of  granular  detritus,  more  or  less  homogeneous  in  char- 
acter, floating  in  a  fluid  known  as  the  Liquor  Puris.  Bacteria  usually 
are  present  also.  The  cells  are  the  leukocytes,  lymphocytes,  and  con- 
nect ive  tissue  cells,  which  formerly  constituted  the  round-cell  infiltra- 
tion of  the  earlier  stages  of  the  inflammatory  process;  but  which  have 
been  killed  by  the  bacterial  toxins,  etc.  The  granular  detritus  consists 
of  the  remains  of  the  cellular  elements  and  intercellular  substance 
of  lymph,  which  have  been  disintegrated  by  the  ferments  (peptones, 
etc.)  generated  during  the  warfare  between  the  bacteria  and  their 
toxins  with  the  body  cells  and  their  bacteriolysins.  The  Liquor 
Puris  is  the  slightly  altered  fluid  exudate  already  described.  In  other 
words,  pus  has  been  produced  from  lymph  by  a  species  of  liquefaction 
necrosis. 

If  pus  is  completely  circumscribed  by  the  body  tissues  it  consti- 
tutes an  abscess.  If  it  is  formed  on  the  surface  of  a  part  it  is  said  to  be 
constantly  "discharged."  If  neither  formed  on  a  surface  nor  well 
circumscribed,  but  rather  diffusely  infiltrated  among  the  body  tissues, 
the  pus  is  said  to  form  a  phlegmon;  and  the  inflammation  is  said  to  be 
phlegmonous  in  type.  In  any  case,  there  is  a  certain  surrounding  area 
where  the  strife  between  the  body  tissues  and  the  invading  micro- 
organisms still  continues.  This  area,  when  surrounding  an  abscess, 
was  formerly  spoken  of  as  a  pyogenic  membrane,  because  it  was  believed 
that  pus  was  secreted  in  the  same  way  as  the  secretion  of  a  gland  is 
produced.  If  the  body  tissues  succeed  in  holding  their  own,  and  the 
invasion  comes  to  a  halt,  then  there  is  formed  in  the  area  surrounding 
the  abscess  what  is  known  as  granulation  tissue;  if,  on  the  other  hand, 
the  body  tissues  continue  to  be  destroyed  by  the  bacteria  and  their 
toxins,  then  the  process  is  described  as  ulceration,  provided  the  change 
occurs  on  a  free  surface  (as  on  the  skin  after  burns,  or  in  the  intes- 
tines in  typhoid  fever,  etc.).  For  although,  from  a  pathological 
point  of  view,  the  process  which  occurs  at  the  so-called  pyogenic 
membrane  of  an  abscess  is  identical  with  that  which  occurs  on  a  free 
surface  on  which  pus  is  being  produced  by  ulceration,  yet  the  latter 
term  is  never  applied  to  the  former  process;  we  merely  say  that  the 
abscess  continues  to  increase  in  size. 

Pus  which  exists  in  the  form  of  an  abscess  may  perhaps  be  absorbed, 
under  exceptional  circumstances,  if  the  amount  of  pus  be  very  small. 
When  this  occurs,  the  granulation  tissue  extends  into  the  puriform 
mass,  the  debris  is  taken  up  by  phagocytes,  and  is  gradually  carried 
away  in  the  blood  and  lymph  channels.  In  other  cases,  where  the 
amount  of  pus  is  small,  and  where  the  abscess  is  deeply  situated, 
the  pus  may  become  encapsulated,  by  the  deposition  in  the  surrounding 
granulation  tissue  of  lime  salts,  or  even  by  the  development  of 
extremelv   dense  fibrous  tissue.     In  such  cases   the  contained   pus 


SUPPURATION  WITHOUT  BACTERIA  27 

gradually  becomes  sterile.  In  all  cases,  however,  in  which  there  is 
any  appreciable  amount  of  pus  present,  the  pus  tends  to  seek  an  exit 
for  itself  in  the  direction  of  least  resistance.  When  the  pus  has  once 
discharged  itself,  the  former  abscess  cavity  will  gradually  assume  the 
character  of  an  ulcerating,  or  rather  of  a  granulating  surface,  and  the 
process  of  repair  will  be  the  same  in  both  instances — that  of  an 
evacuated  abscess  and  that  of  an  ulcer. 

Role  of  the  Nervous  System  in  Inflammation. — In  the  account  of 
inflammation  so  far  given,  no  mention  has  been  made  of  any  part 
played  by  the  nervous  system.  This  is  so,  because  it  plays  only  a 
very  insignificant  part  in  this  process.  Experiments  have  proved  that 
even  when  the  entire  nervous  supply  of  a  part  has  been  cut  off,  the 
phenomena  of  reaction  to  injury,  as  described  above,  occur  without 
appreciable  difference;  from  which  fact  it  may  be  assumed  either  that 
the  local  vascular  system  is  endowed  with  a  nervous  mechanism  of 
its  own  (which  does  not  appear  to  have  been  proved),  or  that  the 
vascular  changes  seen  in  inflamed  areas  take  place  without  the  inter- 
position of  nervous  action.  According  to  Warthin  (1906),  however, 
it  has  been  demonstrated  experimentally  that  removal  of  the  vaso- 
constrictor influence  accelerates,  while  removal  of  the  vaso-dilator 
influence  retards  inflammatory  reaction.  Too  little  is  known  of  the 
pseudo-inflammatory  changes  which  occur  in  the  various  neuropathies 
for  pathologists  to  speak  with  authority  about  them.  It  is  certain, 
nevertheless,  that  under  certain  circumstances  lesions  of  the  nervous 
system  may  very  greatly  influence  the  course  of  inflammation,  as 
seen  in  the  case  of  bed-sores  in  spinal  diseases,  and  in  certain  so-called 
trophic  lesions. 

Extension  of  Inflammation. — -This  occurs  (1)  by  continuity,  as  when 
bronchitis  extends  into  the  pulmonary  tissue,  causing  pneumonia; 
or  when  urethritis  extends  into  the  prostate,  producing  prostatitis;  (2) 
by  contiguity,  as  when  pneumonic  inflammation  extends  to  the  pleura, 
causing  pleurisy;  or  when  peritonitis  developes  from  appendicitis; 
(3)  by  the  lymphatics,  as  when  a  felon  in  the  finger  is  followed  by 
lymphangeitis  and  epitrochlear  or  axillary  lymphadenitis;  or  (4)  by 
the  blood  stream,  as  in  certain  of  the  exanthemata,  and  in  metastatic 
inflammations. 

Terminations  of  Inflammation. — Inflammation  may  terminate  in  two 
ways:  (1)  by  resolution,  a  gradual  return  of  the  part  to  health;  (2) 
by  death  of  the  -patient.  It  is  sometimes  said  that  inflammation  may 
terminate  in  the  local  death  of  the  part  affected ;  but  as  the  surrounding 
parts  will  still  be  the  seat  of  the  inflammatory  process,  or  of  repair, 
until  either  death  or  recovery  terminates  the  disease,  it  is  more  logical 
to  recognize  this  fact  in  our  definition.  The  manifestations  of  the 
local  death  of  a  part  {sloughing,  mortification,  gangrene)  will  be  con- 
sidered in  Chapter  II. 

Suppuration  without  Bacteria. — In  what  has  been  said  above,  it  is 
assumed  that  the  suppuration  described  has  been  caused  by  bacteria; 
and  in  the  immense  majority  of  instances  this  is  the  case.    But  it  should 


28 


l.XFLAMMATlo.X 


not  be  forgotton  that  other  chemical  forms  of  irritation,  as  well  per- 
haps as  certain  mechanical  irritants,  may  produce  pus,  if  their  action 
is  sufficiently  virulent  or  prolonged.  Hypodermic  injections  of  tur- 
pentine, mercury,  croton  oil,  or  other  sterile  substances,  may  cause 
all  the  usual  phenomena  of  inflammation,  and  this  may  proceed  so 
far  that  a  fluid  will  be  formed,  which  will  be  found  to  consist  of  the 
disintegrated  products  of  tissue  metabolism,  and  which  will  be  indis- 
tinguishable from  pus  as  described  above,  except  for  the  facts  that  no 
bacteria  will  be  present,  and  no  phagocytosis  will  be  evident.  It  is 
quite  apparent,  nevertheless,  that,  even  in  such  cases,  the  round-cell 
infiltration,  which  succeeds  to  the  early  hyperemia  and  congestion, 
has  been  produced  by  chemotactic  action  on  the  part  of  the  irritant, 
and  that  the  accumulated  cells  and  tissue  fluids  in  the  process  of 
their  reaction  are  converted  into  substances  which  if  not  technically 
bacteriolysins,  are  some  other  form  of  antibodies  none  the  less  useful 
for  the  defence  of  the  organism. 

Nor  should  it  be  assumed,  on  the  other  hand,  in  every  case  in  which 
inflammation  is  produced  by  bacteria,  that  the  process  necessarily 
will  extend  to  the  stage  of  suppuration.  In  very  many  cases  in  which 
bacteria  are  present,  the  reaction  on  the  part  of  the  body  tissues  is 
sufficient  to  repel  or  to  conquer  the  foe  before  pus  is  formed;  but  it 
is  much  more  usual  for  this  happy  termination  of  the  process  to  occur 
when  the  causes  of  the  inflammatory  reaction  are  sterile.  This  is 
well  seen  in  the  usual  course  pursued  by  clean  wounds. 


Fig.  3. — Staphylococci  in  pus.      X  1000. 
(Frankel  and  Pfeiffer.) 


Fig.  4. — Streptococci  in  pus.      X  1000. 
(Frankel  and  Pfeiffer.) 


Pyogenic  Bacteria.  —  Certain  microorganisms  are  habitually  pyo 
genie;  certain  others  produce  pus  only  under  special  circumstances 
while  a  few  varieties  have  never  been  known  to  cause  suppuration 
It  is,  therefore,  possible  to  classify  pathogenic  bacteria  in  the  follow 
ing  manner:  (1)  Microorganisms  characteristically  leading  to  pus  aim 
abscess  formation — Staphylococcus,  Streptococcus  pyogenes,  Bacillus 


REPAIR  29 

anthracis.  Of  these,  the  varieties  of  the  staphylococcus  denoted  by 
the  suffixes  aureus,  albus,  and  citreus,  and  generically  included  under 
the  term  Micrococcus  pyogenes,  are  those  which  are  especially  asso- 
ciated with  acute,  well-localized  abscesses;  they  are  found  in  felons, 
furuncles,  carbuncles,  acne,  some  cases  of  empyema,  and  certain 
forms  of  periosteitis,  osteomyelitis,  etc.  The  streptococcus,  on  the 
other  hand,  is  associated  with  spreading  infections,  such  as  diffuse 
cellulitis,  erysipelas,  lymphangeitis;  certain  forms  of  osteomyelitis, 
peritonitis,  etc.  The  Bacillus  anthracis  is  the  cause  of  a  specific 
disease,  which  will  be  described  in  Chapter  III.  (2)  Those  causing 
suppuration  only  under  exceptional  circumstances — Pneumococcus, 
Bacillus  typhosus,  Bacillus  coli  communis,  Bacillus  pyocyaneus, 
Gonococcus,  Bacillus  tuberculosis,  etc.  (3)  Those  which  are  never 
known  to  cause  the  formation  of  pus — as  Bacillus  tetani. 

Pathological  Summary. — The  first  action  of  an  irritant  when  intro- 
duced into  the  tissues  is  chemotactic  in  nature;  this  influence  extends, 
without  the  aid  of  the  nervous  system,  to  the  endothelial  and  other 
connective  tissue  cells  lying  in  the  perivascular  tissues;  it  also  extends 
to  the  cells  of  the  vascular  endothelium,  and  even  to  the  white  cells 
of  the  circulating  blood.  The  effect  of  this  positive  chemotaxis  is  to 
slow  the  blood  current  and  to  cause  the  endothelial  cells  of  the  blood- 
vessels to  acquire  agglutinative  properties.  As  a  result,  hyperemia, 
and  later  congestion  is  produced;  margination,  followed  by  migration 
of  leukocytes,  occurs;  exceptionally  diapedesis  of  the  red  blood  cells 
also  is  present.  Round-cell  infiltration  is  produced  in  this  way,  as 
well  as  by  the  multiplication  of  those  cells  already  present  in  the 
inflamed  part.  This  constitutes  the  first  stage  of  inflammation,  that 
of  Temporary  Hypertrophy.  The  warring  hosts  have  been  assembled 
and  the  battle  between  the  invading  microorganisms  and  the  phago- 
cytes is  next  begun;  the  fluid  exudate  aids  the  cells  in  the  fight  by 
means  of  its  bacteriolysins.  Lymph  is  thus  produced,  constituting 
the  second  stage  of  inflammation.  Owing  to  the  progressive  destruc- 
tion of  leukocytes  and  other  cells,  ferments  are  produced,  which 
liquefy  the  lymph,  converting  it  into  pus;  thus  by  pyogenesis,  the 
third  and  last  stage  of  inflammation  is  reached.  In  the  surrounding 
tissues  progressive  destruction  (ulceration)  continues,  or  gradual  repair 
(granulation)  terminates  the  process. 

Repair.  —  It  has  been  pointed  out  (p.  28)  that  the  inflammatory 
process  may  be  terminated  at  any  stage  of  its  course  as  a  result  of  the 
defensive  powers  of  the  organism  overcoming  the  invasion  of  the 
irritant  which  was  the  primary  cause  of  the  inflammation.  Speaking 
generally,  we  may  recognize  three  more  or  less  distinct  ways  in  which 
repair  occurs,  corresponding  to  the  three  stages  of  inflammation 
described. 

1.  If  the  process  of  inflammation  is  arrested  during  the  stage  of 
temporary  hypertrophy,  before  any  exudate  has  been  formed,  the 
migrated  leukocytes  and  other  phagocytes,  having  destroyed  the  bac- 
teria, and  being  no  longer  attracted  by  the  chemotactic  influence  of 


30  INFLAMMATION 

the  invaders,  resume  their  normal  functions  and  return  to  their  usual 
spheres;  the  white  blood  cells  re-enter  the  capillaries,  the  lymph  cells 
swim  away  in  the  lymph  stream,  and  the  site  of  former  inflammation 
can  no  longer  be  distinguished  from  the  surrounding  tissues;  it  is  said 
to  have  undergone  regeneration,  complete  repair,  restitutio  ad  integrum. 
2.  If  the  process  of  inflammation  is  arrested  during  the  stage  of 
lymph  formation,  complete  regeneration  cannot  take  place,  because 
the  tissues  are  not  capable  of  removing  completely  the  results  of  the 
warfare  between  the  irritant  and  themselves.  Some  of  the  cellular 
elements  may  pass  away  again  in  the  blood  and  lymph  streams,  but 
almost  without  exception  a  goodly  number  will  remain  in  the  pre- 


Fig.  5. — Fibroblasts  and  granulation  tissue.  Section  of  a  cutaneous  granulation: 
v  v',  new-formed  capillaries  sprouting  from  depth  of  granulation  and  accompanied  by 
connective  tissue  cells  (c)  and  leukocytes  (I).  A  layer  of  fibrin  (/)  covers  the  surface 
of  the  granulation.  Between  the  superficial  layers  of  the  fibrin  are  seen  large  connec- 
tive tissue  cells  (d')  springing  from  the  granulation  (d).      X  300.      (Cornil  and  Ranvier.) 

viously  inflamed  part,  will  become  converted  into  fibroblasts,  and 
eventually  will  form  scar-tissue.  It  does  not  seem  to  be  certainly 
known  whether  leukocytes  can  become  converted  into  fibroblasts; 
but  there  is  no  doubt  that  most  of  the  fibroblasts  are  produced  from 
endothelial  or  fixed  connective  tissue  cells.  Fibroblasts  are  elongated, 
caudate,  or  spindle-shaped  cells,  occasionally  stellate  in  form. 

The  area  of  inflammatory  exudation  becomes  vascularized  by  the 
out-growth  of  capillaries  from  the  surrounding  bloodvessels.  These 
new  capillaries  grow  as  solid  sprouts;  and  these  solid  processes,  grow- 
ing out  into  the  exudate  of  inflammatory  lymph,  either  meet  other 
similar  out-growths,  or  become  attached  to  a  neighboring  capillary, 


SYMPTOMS  31 

thus  forming  more  or  less  distinct  loops;  these  loops  subsequently 
become  hollowed  out,  and  the  channels  so  formed  are  filled  by  blood 
from  the  surrounding  capillaries.  As  the  process  of  repair  goes  on, 
the  fibroblasts  become  more  and  more  fibrous  in  character  "until  the 
cell  is  represented  by  a  meagre,  attenuated  nucleus,  with  but  a  trace 
of  cytoplasm,  lying  surrounded  by  fibrils — white  connective  tissue.'' 
(Adami.)  The  conversion  of  the  fibroblasts  into  white  connective 
tissue  and  the  invasion  of  the  inflammatory  exudate  by  the  capillary 
loops  go  on  hand  in  hand;  the  tissue  thus  formed  is  known  as  granu- 
lation tissue;  and  when  the  process  occurs  on  a  free  surface  the  capil- 
lary loops  form  the  so-called  granulations.  The  granulation  tissue  is 
at  first  highly  vascular  and  red;  as  the  more  fully  developed  scar- 
tissue  is  formed,  granulation  is  succeeded  by  cicatrization,  and  the 
capillaries  are  squeezed  out  of  existence  as  the  process  of  contraction 
in  the  scar-tissue  continues.  Thus  a  scar  which  at  first  is  red  and 
angry  in  appearance,  eventually  may  become  white,  glistening,  and 
depressed  below  the  surrounding  tissues.  The  area  of  previous  inflam- 
mation, which  during  the  height  of  the  inflammatory  process  was 
swollen  and  tense,  thus  finally  comes  to  occupy  less  space  than  in 
health. 

3.  If  the  process  of  inflammation  has  progressed  to  the  stage  of 
suppuration,  then  in  almost  all  cases  it  is  necessary  for  the  pus  to  be 
discharged  by  the  rupture  of  the  abscess  before  rapair  can  occur. 
It  is  extremely  unusual  for  pus  to  be  absorbed  or  for  scar-tissue  to  be 
formed  unless  the  abscess  has  first  been  converted  into  an  ulcer. 
Repair  in  this  instance,  therefore,  is  best  studied  as  it  occurs  on  a 
free  surface,  and  is  the  same  as  that  which  occurs  in  the  healing  of 
an  ulcer  (p.  52). 

Symptoms. — The  symptoms  of  inflammation  are  local  and  general 
(or  constitutional).  Among  the  latter  are  the  usual  signs  of  fever, 
attended  frequently  by  quickening  of  the  pulse  and  respiration  rate; 
headache,  flushing  of  the  face,  brightening  or  injection  of  the  eyes, 
and  perhaps  delirium  at  night;  anorexia,  with  furred  tongue,  and 
sometimes  nausea;  dry,  hot  skin;  thirst;  usually  the  bowels  are 
constipated,  and  the  urine  high  colored  and  lessened  in  quantity. 
Under  constitutional  symptoms  it  may  also  be  proper  to  include 
leukocytosis,  an  increase  in  the  number  of  leukocytes  present  in  the 
circulating  blood.  This  leukocytosis  is  present  in  almost  all  acute 
inflammations;  it  is  called  forth  by  the  chemotactic  powers  of  the 
irritant,  whose  diffusible  toxins,  when  they  obtain  admission  to  the 
circulating  blood,  are  carried  to  the  bone  marrow  and  other  portions 
of  the  body  whence  leukocytes  are  derived,  and  thus  stimulate  the 
production  of  leukocytes.  In  a  few  diseases,  not  usually  classified 
as  inflammations,  the  influence  of  negative  chemotaxis  is  manifested 
in  the  diminution  of  the  number  of  circulating  leukocytes  (hypo- 
leukocytosis,  leukopenia).  Among  such  diseases  typhoid  fever  and 
tuberculosis  are  the  most  important.  What  were  formerly  called 
critical  discharges  may  occur  either  at  the  approach  of  convalescence, 


32  INFLAMMATION 

or  upon  an  unfavorable  change  in  the  patient's  general  condition. 
These  discharges  are  described  as  diarrhea,  diuresis,  profuse  sweating, 
and  sometimes  hemorrhages  from  the  mucous  membranes.  Their 
significance,  as  well  as  the  probable  causes  and  the  pathology  of 
inflammatory  fever,  will  be  considered  in  Chapter  II  (p.  69).  When 
the  inflammation  is  slight,  constitutional  symptoms  may  be  trivial  or 
entirely  absent;  when  occurring  in  robust,  healthy  individuals,  the 
sthenic  type  of  fever  is  seen;  when  in  the  weak  and  debilitated,  or, 
when  the  inflammation  is  overwhelming,  even  in  the  strong,  a  typhoid 
(asthenic,  adynamic)  type  of  fever  will  result. 

The  local  symptoms  of  inflammation  have  been  described  from  the 
time  of  Celsus  under  the  terms  (1)  Rubor,  or  redness;  (2)  Tumor,  or 
swelling;  (3)  Color,  or  heat;  and  (4)  Dolor,  or  pain;  while  to  these 
classical  symptoms  has  been  added  that  of  (5)  Functio  Lasa  (modifi- 
cation of  function);  and  again  a  sixth  symptom  (6)  Modification  of 
nutrition. 

One  or  more  of  these  local  symptoms  may  be  present  without  the 
disease  constituting  inflammation;  it  may  be  impossible  to  elicit 
evidences  of  one  or  more  of  these  symptoms,  even  when  inflammation 
is  present.  Friction  of  the  skin  may  produce  a  temporary  hyperemia, 
accompanied  by  redness  and  heat,  without  true  inflammation  being 
present;  the  erectile  tissues  furnish  another  example  where  the  pres- 
ence of  one  or  two  symptoms  alone  is  not  sufficient  to  qualify  the 
affection  as  inflammation.  On  the  other  hand,  it  will  be  impossible 
in  many  deep-seated  inflammations  (meningitis,  pleurisy,  etc.)  to 
detect  redness,  and  sometimes  impossible  to  demonstrate  swelling, 
even  though  no  doubt  can  exist  that  inflammation  is  actually  present. 
Some  of  these  local  symptoms  are  more  manifest  in  certain  tissues, 
organs  or  localities,  than  in  others.  Thus  conjunctivitis,  periosteitis, 
orchitis,  are  especially  painful;  cellulitis  is  preeminently  characterized 
by  swelling;  alteration  of  function  is  more  evident  the  more  highly 
specialized  the  tissue  or  organ  affected  (compare  iritis  with  tonsillitis; 
neuritis  with  dermatitis,  etc.);  while  in  the  cornea  and  in  cartilage 
alterations  of  nutrition  may  be  the  only  demonstrable  change. 

Redness  is  nearly  universally  present  in  superficial  inflammations. 
It  is  primarily  due  to  the  hyperemia  and  congestion  of  the  inflamed 
part.  Early  in  the  course  of  the  disease  the  redness  is  bright,  flaming, 
intense,  as  in  erysipelas;  later  it  may  become  bluish  or  almost  purple, 
as  suppuration  or  gangrene  impends.  It  is  not  sharply  outlined  in 
ordinary  forms  of  inflammation,  but  blends  away  in  the  surrounding 
tissues  so  that  it  is  often  impossible  to  define  its  exact  limits.  The 
redness  due  to  inflammation  disappears  when  the  finger  is  pressed 
upon  the  inflamed  spot.  The  rapidity  with  which  the  redness  returns 
after  the  removal  of  pressure  gives  a  fair  idea  of  the  activity  of  the 
circulation;  if  suppuration  or  gangrene  is  threatening  the  circulation 
is  sluggish.  It  should  not  be  forgotten  that  a  sluggish  circulation  may 
be  due  to  organic  disease  of  the  heart,  and  that  this  will  modify  the 
local  manifestations  of  inflammation  even  in  an  early  stage, 


SYMPTOMS  33 

Swelling  is  due  to  the  hyperemia,  to  the  round-cell  infiltrate,  and 
to  the  fluid  exudate  characteristic  of  inflammation.  Thus  tissues 
where  exudation  is  profuse  (eyelid,  scrotum,  and  subcutaneous  tissues 
generally)  show  more  alteration  of  form  than  do  such  structures  as 
bone  or  cartilage.  Blebs  frequently  form  in  the  skin  as  the  result  of 
effusion  of  serum  beneath  the  epidermis;  this  is  seen  especially  in  burns 
and  severe  contusions,  such  as  those  accompanying  fractures  or  dis- 
locations. Swelling  is  beneficial  in  so  far  as  it  tends  to  deplete  the 
overloaded  capillaries;  it  may  be  harmful  by  its  tendency  eventually 
to  block  the  circulation  and  thus  favor  sloughing  or  gangrene.  It 
may  endanger  life  by  occluding  mucous  channels — such  as  the  glottis, 
the  bile  ducts,  the  appendix;  or  by  compressing  the  urethra  when 
the  swelling  occurs  in  the  perineum.  The  swelling  of  the  early  stages 
of  inflammation  is  tense,  and  rather  elastic  to  the  touch;  later  it 
becomes  dense  and  brawny  if  due  to  exudate  which  is  coagulable, 
or  edematous  and  soft  if  due  to  non-coagulable  effusion.  When  an 
inflamed  area  begins  to  "pit  on  pressure,"  it  is  often  indicative  of  the 
presence  of  pus. 

Heat  in  an  inflamed  part  usually  is  appreciable  to  the  hand,  when 
compared  with  a  neighboring  or  similar  part  of  the  patient's  body 
which  is  not  inflamed.  In  arthritis  the  affected  joint  feels  hot,  while 
the  corresponding  joint  does  not.  Local  heat  is  doubtless  produced 
in  large  part  by  the  numerous  chemical  reactions  constantly  occurring 
in  the  inflamed  area.  The  toxins,  bacteriolysins,  ferments,  etc.,  are 
all  of  them  produced  by  forms  of  biochemical  activity  which  thus  far 
are  little  understood.  The  mere  hyperemia  of  the  part  is  not  suffi- 
cient to  account  for  the  heat  present.  Yet  the  local  temperature  is 
rarely  if  ever  higher  than  that  of  the  circulating  blood;  but  it  is  rela- 
tively higher  than  is  that  of  surrounding  parts,  because  there  is  more 
blood  in  the  inflamed  part,  and  especially  near  the  surface  of  the 
inflamed  part,  than  in  surrounding  non-inflamed  parts;  moreover  the 
temperature  of  the  circulating  blood  may  be  higher  than  normal 
(inflammatory  fever),  but  its  abnormal  heat  is  derived  from  the  local 
changes,  not  the  local  heat  from  a  primary  increase  in  the  temperature 
of  the  blood.  The  local  heat  is  greatest  at  the  height  of  the  inflam- 
mation; as  the  disease  progresses  the  local  temperature  falls,  and  when 
suppuration  occurs  it  is  no  longer  above  that  of  surrounding  parts. 
In  the  case  of  gangrene,  the  temperature  of  the  mortified  part  naturally 
becomes  subnormal. 

Pain  due  to  the  inflammatory  process  is  caused  by  tension,  from  cel- 
lular infiltration  and  fluid  exudation,  producing  pressure  on  the  terminal 
nerve  fibers  of  the  part.  The  pain  is  much  less  in  tissues  which  admit 
of  much  swelling  than  in  fibrous  tissues  (felon)  or  bone  (periosteitis) ; 
and  it  may  be  relieved  by  allowing  the  escape  of  the  effusion  through 
incisions.  Inflammation  in  a  part  devoid  of  sensory  nerves  is  not 
attended  by  pain.  Referred  pain  is  to  be  explained  on  anatomical 
grounds,  and  is  due  either  to  pressure  on  a  nerve  trunk,  causing  pain 
in  its  terminal  fibers  (as  in  the  case  of  pain  in  the  knee  due  to  pressure 
3 


34  INFLAMMATION 

on  the  obturator  nerve  at  the  hip);  or  to  overstimulation  of  a  nerve 
causing  an  overflow  of  painful  sensations  into  neighboring  nerves 
derived  from  the  same  spinal  segment:  thus  gall-bladder  disease  may 
cause  pain  in  the  shoulder  through  the  spinal  nerves  derived  from  the 
same  segment  as  that  from  which  the  pneumogastric  takes  its  origin; 
pain  in  the  testicle  follows  disease  of  the  kidney  or  ureter;  inflam- 
mation of  the  neck  of  the  bladder  is  accompanied  by  pain  in  the  head 
of  the  penis;  pleurisy  may  cause  cutaneous  hyperalgesia  of  the  abdo- 
men. The  pain  felt  in  an  inflamed  part  varies  with  the  tissue  affected : 
in  the  skin  (insect  bites,  etc.)  or  mucous  membranes  (conjunctivitis, 
hemorrhoids,  etc.)  it  is  manifested  as  an  itching  or  scalding  sensation; 
in  serous  and  synovial  cavities  it  is  felt  as  a  lancinating  or  stabbing 
pain  (peritonitis,  pleurisy,  synovitis);  in  fibrous  tissues  it  is  dull, 
aching,  or  boring  (periosteitis,  etc.).  Pain  usually  is  greatest  during 
the  height  of  inflammation;  if  the  nervous  structures  are  poisoned 
by  toxins,  the  pain  may  be  slight;  sudden  cessation  of  pain  frequently 
is  indicative  of  gangrene  (appendicitis,  strangulated  hernia).  At  the 
approach  of  suppuration,  the  pain  assumes  a  throbbing  character; 
mortification  is  frequently  announced  by  a  burning  pain. 

Tenderness  on  pressure  is  an  important  modification  of  the  sensa- 
tion of  pain,  and  may  persist  when  pain  has  been  lost  through  gan- 
grene of  the  inflamed  part.  Thus  even  when  the  spontaneous  pain 
of  appendicitis  has  ceased  on  the  occurrence  of  gangrene,  tenderness 
may  still  persist  in  the  surrounding  area  of  the  peritoneum.  If  pain 
is  present  in  a  part  without  local  tenderness,  the  pain  is  referred  pain, 
and  the  seat  of  inflammation  is  elsewhere.  I  have  never  seen  both 
pain  and  tenderness  present  locally  in  an  uninflamed  part,  unless  the 
tenderness  was  a  mere  cutaneous  hyperalgesia.  Mistaking  the  latter 
once  for  a  sign  of  local  disease,  I  removed  a  normal  appendix  vermi- 
formis  from  a  youth  who  twenty-four  hours  later  developed  symptoms 
of  pleuropneumonia. 

Muscular  rigidity  is  due  to  voluntary  or  involuntary  contraction 
of  the  muscles  governing  the  movements  of,  or  protecting  an  inflamed 
part.  Involuntary  contraction  is  due  to  the  impulse  being  referred 
to  motor  instead  of  sensory  nerves,  as  is  the  case  in  referred  pain. 

Impaired  junction  is  more  noticeable  the  more  highly  developed 
the  inflamed  structures.  It  is  an  old  maxim  that  in  inflammation  the 
first  functional  change  is  always  in  the  direction  of  excess.  Parts  which 
possess  normally  very  little  sensation  may  become  acutely  painful; 
glandular  structures  produce  an  abundant,  though  disordered  secre- 
tion; muscular  structures  contract  irregularly  and  spasmodically, 
as  in  fractured  limbs,  and  in  inflammation  of  the  hollow  viscera 
(appendix,  stomach,  gall-bladder,  urinary  bladder,  etc.).  The  special 
senses  are  even  more  affected:  scintillations  of  light  and  photo- 
phobia attend  inflammatory  affections  of  the  eye;  tinnitus  aurium 
is  annoying  in  certain  diseases  of  the  ear;  perversions  of  taste,  of 
smell,  etc.,  are  common  in  affections  of  the  tongue  and  nose.  At  a 
later  stage  of  inflammation  the  function  of  a  part,  instead  of  being 


TREATMENT  OF  INFLAMMATION  35 

stimulated,  is  depressed  or  altogether  abolished:  during  the  height  of 
nephritis,  the  urine  is  suppressed,  and  when  the  secretion  is  restored 
its  nature  may  be  markedly  and  permanently  altered. 

Modification  of  Nutrition. — The  temporary  hypertrophy  seen  in  the 
earlier  stages  may  never  be  recovered  from ;  scars  may  become  keloids ; 
callus  may  never  be  absorbed  entirely;  bones,  the  seat  of  osteo- 
myelitis, may  remain  permanently  thickened;  lymph-edema  may  suc- 
ceed to  cellulitis.  Atrophy,  on  the  contrary,  may  take  the  place  of  a 
return  to  the  normal ;  in  coxalgia  the  head  of  the  femur  may  disappear 
by  interstitial  absorption. 

Chronic  Inflammation. — It  is  an  arbitrary  thing  to  classify  inflam- 
mation as  acute,  subacute,  and  chronic.  The  former  has  been  described; 
the  latter  is  an  inflammatory  affection  of  long  duration,  and  charac- 
terized by  slight  or  moderate  reaction.  Subacute  is  a  mean  between 
the  two.  The  error  should  not  be  made  of  classing  with  chronic  inflam- 
mation certain  results  of  previous  inflammations,  which  consist 
essentially  in  the  formation  of  scar  tissue  or  diffuse  fibrosis.  It  is 
better  to  speak  of  such  changes  as  old  inflammations;  and  to  limit 
the  term  chronic  inflammation  to  a  process  of  reaction  which  is  still 
going  on,  even  if  very  sluggishly.  For  strictly  speaking  a  chronic 
inflammation  is  merely  one  in  which  the  irritant  is  weak,  but  con- 
tinues long  in  action;  in  which  only  a  slight  reaction  is  produced,  and 
in  which  some  factor  prevents  healing.  This  reaction  is  not  wont  to 
go  beyond  the  stage  of  formation  of  granulation  tissue.  The  attacking 
force  and  the  repelling  garrison  are  so  equally  matched  that  neither 
can  well  overcome  the  other;  cell  accumulation  is  marked,  but  phago- 
cytic power  is  slight;  exudation  is  slight;  tendency  to  suppuration  is 
slight.  Such  inflammations  are  seen  in  the  case  of  the  infectious 
granulomas.  When  healing  occurs,  the  scar-tissue  formed  is  propor- 
tionate to  the  previous  hyperplastic  condition. 

The  symptoms  are  similar,  but  less  in  degree,  than  those  seen  in 
acute  inflammation.  As  might  be  expected  from  what  is  known  of 
the  pathology  of  chronic  inflammations,  swelling  is  the  most  char- 
acteristic symptom.  Pain  usually  is  moderate,  but  may  be  intense, 
especially  in  bones  and  joints.  Redness  is  slight.  Heat  often  cannot 
be  detected. 

Treatment  of  Inflammation. — Prophylaxis. — The  consideration  of 
the  treatment  of  inflammation  involves  first  of  all  a  study  of  the 
means  of  prevention.  Inflammation,  even  when  it  has  once  com- 
menced, frequently  may  be  aborted  by  the  prompt  removal  of  the 
cause.  If  the  insult  to  the  tissues  be  due  to  a  foreign  body,  the  removal 
of  the  foreign  body  will  prevent  the  reaction  which  its  prolonged  pres- 
ence undoubtedly  would  provoke.  The  removal  of  a  cinder  from  the 
eye  may  prevent  the  development  of  conjunctivitis;  that  of  a  splinter 
from^the  finger  may  prevent  the  formation  of  a  felon.  Prompt 
extraction  of  shell  fragments  and  pieces  of  clothing,  from  gunshot 
wounds,  may  prevent  the  occurrence  of  gas  gangrene.  In  some 
diseases  and  in  certain  parts  of  the  body,  prompt  excision  or  amputa- 


36  INFLAMMATION 

tion  of  the  diseased  member  will  prevent  the  development  of  an  inflam- 
mation which  might  prove  fatal.  Prompt  amputation  of  a  hopelessly 
mangled  limb  will  prevent  gangrene  and  subsequent  infection;  imme- 
diate removal  of  an  inflamed  appendix  will  abort  the  disease  by 
removing  its  cause,  before  the  inflammatory  reaction  has  spread  to 
the  peritoneum. 

As  bacteria  are  the  most  frequent  causes  of  inflammation,  this  may 
be  most  surely  guarded  against  by  preventing  the  entrance  of  bacteria 
into  wounds,  or  by  removing  them  or  killing  them  after  their  entrance 
has  been  effected.  The  condition  of  the  tissues  when  infected  by 
bacteria  is  known  as  Sepsis;  Asepsis  is  the  condition  when  no  bac- 
teria are  present;  Antisepsis  is  a  method  by  which  bacteria  are  com- 
bated by  certain  chemicals  termed  Antiseptics.  The  constant  use  of 
antiseptics  on  living  tissues  is  open  to  the  objection  that  the  tissues 
are  injured  as  well  as  the  bacteria;  though  it  is  true  that  usually  the 
injury  to  the  tissues  is  insignificant.  When  once  bacteria  have  gained 
entrance  to  the  tissues  there  are  only  two  ways  by  which  their  destruc- 
tion can  be  effected;  the  first  is  by  the  natural  reaction  of  the  tissues 
which  we  call  inflammation,  and  which  may  be  assisted  artificially 
by  the  use  of  sera  or  vaccines  (p.  44),  the  other  method  is  by  the 
direct  introduction  of  antiseptics  into  the  open  wound. 

It  has  been  learned  by  long  and  costly  experience  that  pathogenic 
bacteria  are  everywhere  present  in  civilization,  and  that  mere  ordi- 
nary cleanliness  will  not  suffice  to  exclude  them.  They  are  not 
present  in  the  air,  however,  unless  this  be  dust  laden,  in  number 
sufficient  to  be  harmful;  they  are  carried  from  place  to  place  only 
by  actual  contact  of  instruments,  dressings,  etc.,  on  which  they  may 
have  lodged.  They  may  be  killed  by  boiling,  or  by  dry  heat  at  a 
sufficiently  high  temperature;  and  the  instruments,  dressings,  etc., 
thus  sterilized  will,  therefore,  be  aseptic.  But  unless  the  surgeon's  or 
the  nurse's  hands  be  also  aseptic,  the  mere  momentary  contact  of 
such  hands,  or  of  any  other  unsterilized  thing,  with  the  aseptic 
instruments  or  dressings,  will  at  once  be  liable  to  contaminate  them, 
and  they  will  again  become  septic — to  what  degree  no  one  can  tell. 
Neither  the  hands  of  the  surgeon  nor  the  skin  of  the  patient  can  be 
sterilized  by  boiling  or  by  dry  heat;  but  by  thorough  washing  in 
soap  and  water,  and  by  the  use  of  certain  chemicals,  practically  all 
the  bacteria  present  on  the  surfaces  so  treated  may  be  removed; 
and  those  still  remaining  may  be  rendered  so  inert  that  they  will  be 
incapable  of  exciting  inflammation.  As  an  additional  precaution, 
sterile  gloves  of  thin  rubber  should  be  worn. 

The  introduction  of  the  practice  of  asepsis  and  antisepsis  in  surgery 
dates  from  1867,  when  Lister  published  his  first  observations  on  the 
antiseptic  method  of  wound  treatment;  his  practice  was  founded  on 
and  confirmed  by  the  researches  of  Pasteur,  concerning  fermentation 
and  putrefaction;  and  although  the  science  of  bacteriology  may  be 
said  to  date  from  the  discovery  of  the  Bacillus  tuberculosis  by  Koch, 
in  1882,  the  great  advances  made  in  modern  surgery  undoubtedly  owe 


LOCAL   REMEDIAL  TREATMENT  37 

their  existence  to  Lister's  initiative.  When  no  antiseptics  were  used, 
the  healing  of  wounds  was  tedious  in  the  extreme,  and  the  inflammatory 
reaction  practically  always  extended  to  the  stage  of  pus  formation. 
Since  the  introduction  of  the  practice  of  asepsis  and  antisepsis,  sur- 
geons have  become  accustomed  to  having  their  wounds  heal  with 
little  or  with  no  apparent  inflammatory  reaction.  Oilier  reported  a 
mortality  of  80  per  cent,  from  excisions  of  the  knee  before  adopting 
the  antiseptic  method;  after  adopting  this  method,  his  mortality 
fell  to  14  per  cent.1 

Asepsis  is  generally  acknowledged  to  be  better  than  antisepsis, 
whenever  it  is  practicable.  In  operative  wounds  asepsis  is  usually 
possible;  but  when  the  wound  is  infected  before  it  comes  under  the 
surgeon's  care,  it  is  usually  safer  to  adopt  antiseptic  principles. 
Wounds  and  wound  treatment  are  discussed  in  Chapter  VI. 

Cure  of  Inflammation. — The  remedial  treatment  of  inflammation 
may  be  divided  into  the  Local  and  the  Constitutional.  Under  the 
former  head  are  included  such  methods  as  Rest  of  the  inflamed 
part;  its  Position;  the  use  of  Heat  and  Cold;  Narcotics  and  Counter- 
irritants;  Bleeding,  Leeching,  etc.;  Incisions  and  Operations;  Compres- 
sion; Active  and  Passive  Congestion;  Massage,  etc.  Under  the  latter 
will  be  considered  Constitutional  Rest;  Diet;  Drugs;  and  the  curative 
use  of  vaccines  and  sera. 

Local  Remedial  Treatment. — Rest  of  the  inflamed  part  is  desirable 
to  decrease  the  hyperemia  and  congestion,  when  these  are  excessive; 
to  lessen  the  cellular  infiltrate  and  the  exudation;  and  to  enable  all 
the  forces  of  nature  to  be  exerted  in  overcoming  the  causes  of  disease, 
instead  of  expending  their  strength  in  unnecessary  physiological  pro- 
cesses which  functional  use  of  the  part  would  entail.  Rest  in  bed  is 
indispensable  in  a  great  many  inflammations  of  the  head,  trunk,  and 
lower  extremities.  Rest  may  be  procured  by  the  use  of  splints,  when 
these  are  sufficient,  as  in  many  fractures,  wounds  of  the  extremities, 
felons,  etc.;  by  gypsum  cases  when  rest  for  a  longer  period  is  desirable, 
as  in  inflammations  of  certain  joints;  by  bandages,  or  strapping  with 
adhesive  plaster,  as  in  fractures  of  the  ribs,  slight  sprains,  etc.  Finally 
rest  may  be  procured  by  position. 

Position  is  of  importance,  because  neglect  to  elevate  an  inflamed 
part,  and  thus  to  prevent  or  lessen  congestion,  may  markedly  increase 
the  pain;  may  favor  the  occurrence  of  suppuration  or  sloughing; 
or  invite  gangrene  by  interference  with  the  natural  circulation  of  the 
part.  Carrying  the  hand  in  a  sling;  keeping  the  foot  elevated  on  a 
stool;  or  even  going  to  bed  for  a  time,  will  each  of  them  prove  of 
benefit  in  special  cases. 

1  It  is  true  that  the  late  Prof.  Ashhurst  (1895),  in  a  series  of  84  excisions  of  the 
knee-joint,  had  a  mortality  of  only  8.3  per  cent.,  the  series  extending  through  both 
pre-antiseptic  and  antiseptic  periods;  yet  it  is  to  be  noted  that  he  uniformly  used 
scrupulous  cleanliness,  and  virtual  antiseptics  (turpentine,  alcohol,  potassium 
permanganate)  even  before  adopting  Lister's  principles  of  wound  treatment. 


38  INFLAMMATION 

Cold  is  an  invaluable  agent  in  the  treatment  of  inflammation  in  its 
early  stages.  It  is  anesthetic,  benumbing  the  part  and  lessening  pain; 
it  constricts  the  bloodvessels,  decreasing  the  hyperemia,  and  some- 
times preventing  excessive  effusion;  and  it  is  not  impossible  that  it 
lessens  the  physiological  activities  of  a  part,  thus  promoting  rest. 
It  probably  lessens  peristalsis  in  cases  of  peritonitis.  Its  chief  use, 
however,  is  in  inflammations  of  traumatic  origin — wounds  of  the  soft 
] tarts,  sprains,  etc. 

It  may  be  applied  either  dry  or  moist.  The  use  of  moist  cold  is  apt 
to  macerate  the  skin;  but  for  short  periods  of  time  moist  cold  is  very 
useful,  as  well  in  open  wounds  as  in  the  case  of  subcutaneous  injuries. 
In  crushes  of  the  extremities  it  is  often  possible  to  prevent  wide- 
spread sloughing  by  the  use  of  irrigation.  If  more  elaborate  appli- 
ances are  not  at  hand,  a  pitcher  may  be  hung  over  the  affected  part 
and  a  strip  of  gauze  arranged  to  act  by  syphonage  (Fig.  127).  Dry 
cold  is  most  conveniently  applied  by  means  of  the  ice  bag;  in  using 
this,  care  should  be  taken  to  see  that  a  fold  of  dry  lint  or  a  dry  towel 
is  kept  between  the  skin  and  the  ice  bag,  as  the  condensation  on  the 
surface  of  the  latter  will  soon  render  the  skin  wet,  and  may  cause 
superficial  sloughing.  Or  Petitgand's  method  of  mediate  irrigation 
may  be  employed:  a  coil  of  thin-walled  rubber  tubing,  of  convenient 
length,  is  wrapped  around  the  limb,  or  applied  to  the  head,  the  breast, 
etc.,  and  is  held  in  place  by  a  few  turns  of  a  roller  bandage;  a  stream 
of  cold  water  is  then  allowed  to  trickle  constantly  through  the  tube, 
being  collected  beside  the  bed  in  a  suitable  receptacle.  The  tempera- 
ture to  which  the  surface  of  the  inflamed  part  has  been  reduced  may  be 
ascertained  by  testing  the  fluid  as  it  runs  off.  Leiter's  coils,  which 
may  be  purchased  ready  made,  are  of  flexible  metal. 

Heat,  like  cold,  constringes  the  vessels  of  an  inflamed  part,  and 
though  not  actually  anesthetic,  may  prove  more  grateful  to  the  patient. 
In  the  form  of  a  hot  water  bag,  dry  heat  is  a  household  remedy. 
Baking  is  a  valuable  remedy  in  chronic  inflammation.  Moist  heat  is 
more  often  employed  in  acute  inflammation  than  is  dry.  It  is  useful  in 
sprains,  etc.,  as  an  early  application  (hot  water  bath),  having  a  tend- 
ency to  limit  or  to  prevent  the  development  of  subcutaneous  edema. 
It  is  much  more  stimulating  than  cold,  and  when  the  circulation  is 
sluggish,  and  sloughing  is  threatened,  the  surgeon  may  sometimes 
avert  the  danger  by  the  use  of  very  hot  compresses  frequently  renewed. 
The  use  of  moist  heat  in  the  form  of  a  poultice  is  very  agreeable  to 
the  patient,  and  is  one  of  the  most  efficient  ways  of  promoting  sup- 
puration when  this  is  inevitable,  as  well  as  in  hastening  the  separation 
of  sloughs  when  these  have  once  formed.  The  poultice  may  be  made 
aseptic  by  sterilizing  its  ingredients. 

It  is  sometimes  said  that  there  is  no  need  to  use  antiseptics  in 
wounds  which  already  are  infected,  and  that  further  infection  will 
do  good  by  establishing  a  free  discharge  of  pus.  This  is  an  error;  if 
there  is  no  discharge  of  laudable  pus  in  infected  wounds,  it  only 
shows  that  the  inflammation  is  extending,  and  that  the  body  tissues 


LOCAL  REMEDIAL  TREATMENT  39 

have  not  been  able  to  produce  a  sufficient  number  of  phagocytes  to 
combat  and  to  vanquish  the  invaders.  Adding  to  the  infection,  or 
producing  a  mixed  infection,  will  not  mend  matters;  it  should  rather 
be  the  surgeon's  care  to  support  his  patient's  strength,  and  to  aid  his 
tissues  in  the  unequal  struggle  by  destroying  as  many  as  possible  of 
the  microorganisms  already  present. 

The  alternation  of  heat  and  cold,  in  the  form  of  douches,  is  useful  in 
the  later  stages  of  the  inflammatory  process,  aiding  in  the  absorption 
of  exudates  and  the  restoration  of  the  part  to  the  normal  condition. 

Narcotics  sometimes  are  applied  locally  with  benefit.  The  tincture 
of  arnica,  lead  water  with  laudanum  or  alcohol,  and  lately  magnesium 
sulphate,  have  been  popular  at  various  times.  The  last  named  sub- 
stance has  the  effect  of  a  local  anesthetic,  and  very  remarkable  effects 
are  claimed  from  its  use  in  erysipelas  (Tucker,  1908),  arthritis,  orchitis, 
and  other  affections.  Belladonna  plaster  is  a  favorite  domestic  remedy. 
Ichthyol,  in  the  form  of  an  ointment  of  10  to  25  per  cent,  strength, 
is  useful  in  soothing  the  pain  of  adenitis,  in  furuncles,  etc.,  and  by  its 
sorbefacient  effect  seems  to  exert  a  directly  beneficial  influence  on  the 
course  of  inflammation.  Ointments  of  belladonna  and  mercury  are 
used  in  the  same  way.  The  internal  use  of  mercury  and  the  iodides 
may  be  combined  advantageously  with  these  local  applications. 

Counter-irritants,  when  applied  around  but  not  directly  over  the 
inflamed  part,  are  often  productive  of  considerable  benefit,  especially 
in  subacute  and  chronic  inflammations,  though  their  exact  mode  of 
action  is  still  a  matter  of  dispute.  Under  this  heading  come  blisters, 
iodin,  turpentine  stupes,  capsicum  and  mustard  plasters;  also  silver 
nitrate,  which  is  astringent,  and  copper  sulphate.  The  actual  cautery 
is  occasionally  of  value  as  a  counter-irritant. 

Local  bleeding,  by  the  use  of  incisions,  or  by  means  of  leeches,  may 
be  of  value  in  combating  excessive  inflammatory  reaction.  It  will 
relieve  the  congestion,  may  perhaps  prevent  the  formation  of  a  harm- 
ful exudate,  and  almost  without  exception  diminishes  the  pain. 
Leeches  are  seldom  employed  at  the  present  day  except  in  affections 
of  the  eye  and  ear.  Venesection,  or  general  bleeding,  is  now  rarely 
employed.  In  cerebral  compression  its  use  is  illogical,  since  the 
increased  arterial  tension  is  the  effect,  not  the  cause,  of  the  lesion 
within  the  cranium.  But  in  the  robust,  plethoric,  or  cyanosed,  with 
symptoms  of  present  or  threatening  toxemia,  in  the  presence  of 
inflammation  of  the  sthenic  type,  venesection  is  sometimes  of  value. 

The  use  of  incisions  has  already  been  referred  to  under  the  head 
of  bleeding;  by  relieving  tension  they  serve  to  lessen  the  pain,  and 
may  prevent  sloughing  by  promoting  discharge  from  the  over-filled 
vessels  of  the  inflamed  area,  thus  aiding  in  the  restoration  of  the 
circulation.  The  pain  of  orchitis  is  readily  relieved  by  puncture  of 
the  tunica  albuginea;  after  plastic  operations  (for  hypospadias,  etc.) 
multiple  small  incisions  may  prevent  sloughing  by  reducing  the 
edema;  in  extensive  cellulitis  the  use  of  free  incisions  may  prevent 
the  development  of  widespread  sloughing  or  gangrene  (as  in  extrava- 


40  INFLAMMATION 

satioii  of  urine).  Finally  the  evacuation  of  pus  is  one  of  the  main 
indications  for  incision. 

Operations  are  frequently  required  in  the  treatment  of  inflamma- 
tion. Drainage  must  be  established  in  suppurative  affections  in  all 
parts  of  the  body  (brain  abscess;  empyema;  peritonitis);  an  invo- 
luerum  must  be  cut  away;  sequestra  must  be  removed;  amputation 
and  excisions  must  be  performed,  before  the  ultimate  cure  of  the 
disease  can  be  effected. 

Compression,  applied  before  the  inflammatory  process  has  reached 
its  height,  may  prevent  excessive  reaction;  in  the  later  stages  it  will 
assist  in  promoting  absorption.  Swelling  of  a  sprained  ankle  may  be 
prevented  by  strapping;  a  carbuncle  will  rapidly  decrease  in  size  when 
thoroughly  suported  at  its  periphery  by  adhesive  plaster  straps; 
strapping  a  leg  ulcer  is  almost  indispensable  at  times. 

Active  mid  passive  congestion,  as  introduced  by  Bier  (1905),  are 
useful  in  some  inflammatory  affections.  Congestion  lessens  the  pain 
by  benumbing  the  part,  probably  by  direct  pressure  on  the  nerve 
endings  through  the  subcutaneous  edema  produced,  acting  thus 
much  like  the  usual  forms  of  infiltration  anesthesia.  It  produces  its 
curative  effect  probably  by  increasing  the  number  of  phagocytes  in 
the  part;  possibly  also  by  increasing  the  quantity  of  the  exudate 
and  thus  enhancing  its  bactericidal  properties.  It  has  seemed  to 
me  that  the  value  of  compression  in  carbuncles  and  chronic  ulcers 
may  be  due  at  least  in  some  measure  to  the  chronic  passive  hyper- 
emia produced.  Passive  congestion  is  most  used  in  the  treatment  of 
chronic  arthritis;  it  is  also  of  value  in  such  localized  infections  as 
furuncles,  felons,  etc.;  it  is  usually  useless  or  actually  harmful  in 
spreading  inflammations.  Passive  congestion  is  to  be  secured  by 
bandaging  the  limb  some  distance  above  the  lesion  with  an  elastic 
bandage  which  is  drawn  tight  enough  to  obstruct  the  venous  current 
without  intercepting  the  arterial.  The  limb  below  the  seat  of  the  con- 
striction should  develop  a  comforting  glow,  the  superficial  venules 
being  distended,  and  the  skin  becoming  a  dusky  blue.  Under  no  cir- 
cumstances should  the  constriction  be  tight  enough  to  cause  a  fall  of 
temperature  in  the  limb.  At  first  the  treatment  is  continued  for  only 
one  hour  daily,  but  later  may  be  used  almost  continuously,  i^ctive 
hyperemia  is  secured  by  hot  air  applications  (baking  or  the  hot  air 
douche),  or  by  the  use  of  cupping  glasses,  which  are  made  in  forms 
suitable  to  the  various  parts  affected.  Baking  is  particularly  applicable 
to  chronic  forms  of  arthritis  without  effusion;  while  the  cupping  glass 
apparatus  is  said  to  be  of  value  in  the  treatment  of  chronic  sinuses, 
etc. ;  it  has  also  been  used  in  uterine  affections. 

Massage  is  of  value  in  the  later  stages  of  inflammation,  by  pro- 
moting absorption  of  the  exudate,  rupturing  slight  inflammatory  adhe- 
sions; and  thus  aiding  the  restoration  of  normal  physiological  action. 
In  enforced  confinement  to  bed,  massage  may  be  advisable  to  sustain 
the  tone  of  the  muscles  of  those  parts  not  directly  concerned  in  the 
disease. 


CONSTITUTIONAL  TREATMENT  41 

Constitutional  Treatment. — Constitutional  rest,  as  well  as  local  rest 
of  the  inflamed  part,  is  often  requisite.  Rest  in  bed,  in  a  quiet,  cool, 
darkened  room,  may  enable  the  patient  to  be  restored  to  his  activi- 
ties in  a  few  days,  whereas  a  much  longer  period  frequently  would  be 
required  were  he  to  persist  in  going  about  the  house.  Especially 
should  such  rest  be  insisted  upon  in  the  case  of  acute  inflammations 
of  the  chief  organs  of  the  body — pyelitis,  cystitis,  prostatitis,  affec- 
tions of  the  gall-bladder  and  other  abdominal  organs. 

Hygiene  is  of  the  utmost  importance.  The  room  of  the  patient, 
or  the  hospital  ward,  should  be  well  ventilated,  and  easily  warmed 
in  winter,  and  cool  in  summer.  Bathing  must  not  be  neglected,  for 
the  skin  is  an  important  excretory  organ.  The  excretions  must  be 
watched  daily,  and  in  most  cases  a  careful  examination  of  the  urine 
should  be  made,  both  as  to  quality  and  quantity.  Cathartics  should 
be  given  as  needed;  a  brisk  purge  early  in  the  attack  is  usually  bene- 
ficial. A  temperature  chart  should  be  kept,  and  the  temperature, 
pulse,  and  respiration  be  recorded  twice  daily.  As  the  patient  will 
often  be  unable  to  entertain  himself  while  laid  up,  the  surgeon  should 
see  that  such  light  entertainment  as  is  deemed  suitable  is  provided. 
The  best  surgeons  are  physicians  also,  and  must  not  let  their  pro- 
fessional duty  cease  with  the  dressing  of  the  wound  or  the  applica- 
tion of  a  splint.  On  the  other  hand,  I  have  sometimes  seen  patients 
who  were  exhausted  by  over-entertainment,  all  the  members  of  the 
family  congregating  in  the  sick  man's  room  to  spend  the  evening, 
vitiating  the  atmosphere,  and  wearying  the  patient's  mind  by  constant 
chattering  among  themselves.  It  is  usually  well  to  limit  the  visitors 
to  two  at  a  time;  and  to  caution  them  to  cease  their  visit  and  their 
conversation  when  the  sick  man  no  longer  appears  interested. 

The  diet  in  cases  of  inflammation  should  be  simple;  so  long  as  fever 
continues,  liquid  diet  is  preferable.  Milk,  which  is  the  most  univer- 
sally applicable  article  of  food,  usually  can  be  taken  by  any  patient, 
in  spite  of  his  prejudices,  if  he  makes  the  attempt,  and  if  the  milk  is 
fresh  and  cold.  A  few  patients  prefer  it  warmed.  Its  taste  may  be 
disguised  by  the  use  of  vanilla,  chocolate,  coffee,  etc.  All  kinds  of 
broths  are  suitable;  fresh  beef  juice  often  is  relished,  or  the  various 
prepared  forms  of  meat  juice  may  be  employed.  When  the  fever  has 
gone,  more  liberal  diet  may  be  allowed:  eggs,  oysters,  sweetbreads, 
chicken,  chops,  green  vegetables,  ice-cream,  etc.  As  a  rule,  the 
patient's  own  desires  and  tastes  furnish  a  fairly  reliable  guide  to  his 
diet;  and  if  no  injurious  effects  are  manifest,  he  may  be  permitted  to 
eat  pretty  much  what  he  pleases. 

Drugs  are  of  undoubted  value  in  the  treatment  of  inflammation. 
Those  most  employed  may  be  classed  as  (1)  Sedatives;  (2)  Cathartics; 
(3)  Diuretics  and  Diaphoretics;  (4)  Stimulants;  (5)  Alteratives;  (6) 
Tonics. 

Sedatives.— Opium  is  one  of  the  most  valuable  single  remedies  in 
the  pharmacopoeia;  but  its  tendency  to  produce  constipation  must 
be  guarded  against;  and  it  is  too  valuable  a  remedy  to  be  used  indis- 


I-'  IN  FLAM  MM' ION 

criminately.  It'  the  patient  is  in  pain,  it  is  the  surgeon's  duty  to 
relieve  the  pain  so  far  as  is  compatible  with  the  cure  of  the  disease; 
but  usually  pain  may  be  relieved  without  resort  to  opium,  by  change 
of  position,  by  prompt  incision  of  an  abscess,  or  by  rest  enforced  by 
splint  or  bandages.  If  the  pain  really  demands  morphin  for  its  relief, 
I  think  it  is  usually  better  to  administer  one-sixth  of  a  grain  hypo- 
dermically,  and  to  repeat  this  in  an  hour  if  the  patient  is  not  relieved. 
Closely  allied  to  its  power  of  producing  sleep  is  the  action  of  opium 
for  injuries  of  the  head,  in  traumatic  delirium,  delirium  tremens,  etc. 
Besides  relieving  pain  and  securing  sleep,  opium  serves  to  relax 
spasm;  it  thus  proves  of  benefit  in  fractures,  in  retention  of  urine 
from  congestion  of  the  posterior  urethra,  in  fissure  of  the  anus,  in 
pylorospasm  and  similar  affections. 

If  opium  is  contraindicated,  other  sedatives  may  take  its  place; 
among  the  most  valuable  of  these  are  chloral,  the  bromides,  hyoscin, 
cannabis  and  paraldehyde.  Trional  is  a  useful  hypnotic,  but  has 
no  influence  on  pain.  Aconite  may  be  given  in  small  doses  during  the 
height  of  the  inflammatory  fever,  when  of  the  sthenic  type. 

Cathartics  usually  may  be  administered  with  benefit  in  the  early 
stages  of  inflammation.  In  this  way  toxins  are  withdrawn  from  the 
circulating  blood,  and  prevented  from  reaching  the  kidneys  in  excess, 
where  they  are  prone  to  cause  cloudy  swelling  or  desquamative  neph- 
ritis. In  peritonitis  I  believe  the  use  of  cathartics  to  be  positively 
harmful.  In  meningitis  it  is  desirable  to  keep  the  bowels  freely  open. 
A  single  dose  of  castor  oil,  or  blue  pill,  or  divided  doses  of  calomel 
will  be  of  more  benefit  in  most  cases  than  the  popular  use  of  salts. 
After  having  the  bowels  thoroughly  opened  once,  it  is  usually  inad- 
visable to  continue  purging  the  patient.  If  constipation  persists, 
enemas  may  be  used.  Asafcetida  suppositories,  or  milk  of  asafcetida 
by  enema,  are  supposed  to  overcome  flatulence.  I  have  considerable 
doubt  whether  they  have  any  very  definite  action. 

Diuretics  and  diaphoretics  were  much  employed  formerly,  and 
they  undoubtedly  are  of  benefit  in  some  cases.  Plenty  of  water  by 
mouth  is  the  best  diuretic;  when  this  is  contraindicated,  or  if  it  can- 
not be  taken,  resort  may  be  had  to  rectal  infusion  of  water  (p.  145) 
or  to  subcutaneous  or  intravenous  injections  of  saline  solution.  The 
kidneys  are  the  chief  organs  of  elimination  for  the  toxins  produced 
at  the  seat  of  inflammation,  and  by  the  imbibition  of  plenty  of  fluid 
the  function  of  the  kidneys  is  promoted,  and  the  toxins  are  excreted 
in  a  more  or  less  diluted  form. 

Dover's  powder  combines  the  merits  of  an  hypnotic  with  those 
of  a  diaphoretic.  The  vegetable  salts  of  potassium  and  ammonium 
(citrate  and  acetate)  are  especially  valuable  as  diuretics  because  they 
are  not  themselves  irritating;  moreover,  they  lessen  the  viscosity  of 
the  blood.  Digitalis  and  strophanthus  are  more  stimulating;  these,  or 
the  citrate  of  caffein,  may  be  used  when  the  heart  shows  signs  of  failure. 

Stimulants  seldom  can  be  dispensed  with  in  severe  cases  after  the 
height  of  the  fever  has  passed.    Alcohol,  when  taken  in  small  quanti- 


CONSTITUTIONAL  TREATMENT  43 

ties,  aids  the  absorption  of  food ;  it  seems  to  act  almost  as  a  food  itself 
when  little  else  can  be  retained.  It  should  be  given  in  doses  large 
enough  to  produce  the  desired  effect;  the  amount  naturally  will  vary 
with  the  age  and  habits  of  the  patient,  with  his  general  condition, 
and  with  the  condition  of  his  heart  and  kidneys.  The  initial  dose 
should  be  small  (15  c.c.  three  or  four  times  daily),  and  it  should  be 
increased  rapidly  so  long  as  it  appears  to  do  good.  In  meningitis  it 
is  contra-indicated,  as  tending  to  increase  delirium;  but  in  delirious 
states  due  purely  to  adynamia,  as  in  extensive  burns  or  other 
exhausting  diseases,  the  use  of  tonic  doses  of  alcohol  frequently  will 
cause  the  mental  state  to  clear  up  prompt!}'.  Its  use  in  delirium 
tremens  is  to  be  condemned.  If  the  delirium,  from  any  cause,  is 
increased  by  the  alcohol,  it  is  doing  the  patient  no  good,  and  should 
be  reduced  in  quantity  or  discontinued  entirely.  Whisky  and  brandy 
are  the  best  forms  in  which  to  administer  alcohol  during  the  inflam- 
mation; during  convalescence,  ale,  beer,  porter,  or  the  lighter  wines 
may  be  used.  Champagne  is  the  only  form  in  which  it  is  usually 
advisable  to  administer  alcohol  during  the  continuance  of  high  fever. 

Coffee,  which  may  be  administered  by  mouth  or  by  enema,  is  a 
valuable  stimulant.  So  is  salt  solution,  as  already  noted  when  speak- 
ing of  diuretics.  Atropin,  digitalis,  and  camphor  are  good  cardiac 
and  vascular  stimulants. 

Alteratives  are  used  frequently  in  inflammation.  Antimony  was 
formerly  employed  in  the  endeavor  to  abort  inflammation  by  means 
of  its  so-called  "anticipatory  antiplastic  effect."  Calomel,  for  the 
same  purpose,  was  strongly  commended  by  the  late  Prof.  Ashhurst, 
in  the  treatment  of  head  injuries,  and  I  constantly  employ  it  with 
utmost  satisfaction.  The  employment  of  mercury  to  cause  the  ab- 
sorption of  inflammatory  exudates  (iritis,  meningitis,  etc.)  is  world- 
wide. Calomel  is  usually  the  best  form  for  administration.  The 
iodides  of  potassium,  sodium,  etc.,  are  widely  used  to  aid  in  the 
elimination  of  inflammatory  products,  especially  in  affections  of  the 
bones  and  joints. 

Tonics. — During  convalescence  it  is  almost  always  proper  for  the 
patient  to  take  a  tonic.  Iron  and  quinin  are  the  most  valuable. 
Some  patients  will  prefer  Blaud's  pills  to  the  tincture  of  the  chloride 
of  iron,  but  the  latter  frequently  is  more  effective.  The  tincture  of 
nux  vomica,  or  strychnin  sulphate,  with  one  of  the  bitters,  aids 
materially  in  the  restoration  of  appetite.  In  the  case  of  children, 
cod  liver  oil,  the  syrup  of  the  iodide  of  iron,  the  phosphates,  or  arsenic 
may  be  given. 

Stimulation  of  Phagocytosis. — This  method  has  been  attempted  in 
both  the  prevention  and  treatment  of  inflammation.  Mikulicz  used 
local  hypodermic  injections  of  dilute  nucleinic  acid,  in  the  effort  to 
increase  by  positive  chemotaxis  the  number  of  phagocytes  and  their 
bactericidal  power  for  the  prevention  of  peritonitis.  Local  inunctions 
of  mercury  are  said  to  act  in  a  similar  way.  The  use  of  Bier's  passive 
hyperemia  has  already  been  referred  to. 


I  I  INFLAMMATION 

Vaccines  and  Serum  Therapy  in  General.  The  phenomena  of  the 
inflammatory  process  arc  merely  exaggerations  of  phenomena  which 
arc  constantly  occurring  in  the  body  in  a  state  of  health.  As 
already  mentioned,  it  is  extremely  probable  that  bacteria  of  some 
kind  are  constantly  present  in  the  body,  and  that  phenomena  of 
disease  are  prevented  only  by  the  natural  resistance  of  the  body 
tissues.  Opsonins,  as  pointed  out  at  p.  23,  are  normally  present  in 
the  fluids  of  the  circulating  blood.  When  local  inflammation  or 
general  disease  arises,  these  resistive  powers  of  the  organism  are 
increased;  various  other  antibodies  are  produced,  and  on  recovery 
from  a  certain  disease  a  condition  of  immunity  to  that  special  infec- 
tion may  be  established,  and  may  continue  for  a  longer  or  a  shorter 
time.  This  immunity  may  be  conceived  of  as  being  due  to  the  cells 
of  the  body  having  acquired  by  training  the  habit  of  resisting  a  certain 
specific  infection;  so  that  should  this  same  infection  again  occur,  the 
body  cells  would  be  fully  prepared,  as  the  result  of  their  previous 
experience,  to  act  rapidly  and  effectively  in  repelling  the  foe.  Their 
habit  of  forming  antibodies  persists,  and  will  result  in  attempts  at 
re-infection  proving  ineffectual. 

The  earliest  instance  in  which  practical  application  was  made  of 
the  above  theory,  though  of  course  the  principle  itself  was  not  then 
understood,  was  the  use  of  vaccination  by  Jenner  (1798);  in  the  origi- 
nal method  the  virus  of  the  cowpox  was  inoculated  into  man,  thus 
producing  in  him  the  disease  known  as  vaccinia,  which  was  considered 
to  be  a  mild  form  of  smallpox,  the  virulence  of  the  smallpox  virus 
having  been  attenuated  by  passing  through  the  cow.  By  thus  training 
the  body  cells  to  reaction  against  the  virus  of  cowpox,  an  immunity 
to  smallpox  is  established. 

The  term  vaccines  is  applied  to  those  substances,  used  for  pro- 
phylactic or  curative  injection,  which  contain  the  attenuated  virus 
itself,  not  merely  some  of  the  anti-bodies  produced  in  the  course  of 
the  disease.  Most  vaccines  contain  no  bacteria  which  have  not  been 
killed.  Those  substances  which  contain  anti-bodies  and  perhaps 
dead  bacteria,  but  certainly  no  living  virus,  are  classed  as  sera ;  they  are 
subdivided  into  antitoxic  and  antibacterial  sera. 

Prophylaxis  and  treatment  by  vaccines  and  sera  are  most  suc- 
cessful in  the  case  of  diseases  caused  by  specific  microorganisms. 
Ordinary  inflammations,  in  wThich  the  cause  is  not  a  specific  micro- 
organism, have  not  so  far  been  treated  with  very  encouraging  results. 
Among  diseases  treated  by  vaccines  may  be  mentioned,  besides  the 
prevention  of  smallpox  already  referred  to,  the  prophylaxis  and  cure 
of  anthrax  (Pasteur),  rabies  (Pasteur),  typhoid  fever  (Frankel, 
Richardson),  and  tuberculosis  (Koch,  Wright).  Among  those  treated 
by  sera  are  included:  (1)  By  antitoxic  sera,  diphtheria  (Behring), 
tetanus  (Behring) ;  (2)  By  antibacterial  sera,  typhoid,  cholera,  plague, 
dysentery,  etc.  Finally  by  the  administration  of  both  vaccines  (active 
immunization)  and  sera  (passive  immunization),  encouraging  results 
have  been  obtained  in  anthrax  by  Sclavo  (1903). 


VACCINES  AND  SERUM  THERAPY  IN  GENERAL  45 

Antistreptococcic  serum  has  been  used  in  ordinary  types  of  spread- 
ing inflammation,  in  erysipelas,  and  in  septicemia.  (See  Chapter  II.) 
It  is  an  antibacterial  serum.  The  results  are  sometimes  marvellous, 
while  more  often  its  use  appears  to  be  devoid  of  effect  of  any  kind. 
Anticolon  bacillus  serum  has  been  used  by  some  observers,  but 
without  very  constant  results.  As  a  general  statement,  it  may  be 
said  that  in  acute  diseases,  where  it  is  necessary  to  supply  the  patient 
with  anti-bodies  already  formed,  sera  are  used;  while  in  chronic  infec- 
tions, it  is  hoped  by  the  administration  of  killed  bacteria  to  rouse 
the  patient's  tissues  to  a  more  effectual  production  of  anti-bodies. 


CHAPTER  II. 

DISEASES  RESULTING  FROM  INFLAMMATION. 

The  surgical  diseases  resulting  from  inflammation  may  be  classified 
as  (1)  Local  Affections,  including  Abscess,  Ulcer,  Gangrene,  Cellulitis, 
Erysipelas,  etc.;  and  (2)  General  Affections,  including  under  the  gen- 
eral name  of  Sepsis,  the  varieties  of  systemic  infection  known  as 
Sapremia,  Toxemia,  Bacteriemia  (Septicemia),  and  Pyemia. 

LOCAL  AFFECTIONS. 

Abscess. — The  pathogenesis  of  an  abscess  has  been  described 
already  (p.  25),  and  it  may  be  defined  as  a  collection  of  pus  circum- 
scribed by  granulation  tissue.  If  the  pus  is  not  circumscribed  by 
granulation  tissue,  it  is  not  spoken  of  as  an  abscess.  Thus  pus  in  the 
pleural  cavity  is  an  empyema,  if  widely  diffused;  it  does  not  become 
an  abscess  until  it  is  walled  off  from  the  general  cavity  by  the  effusion 
of  lymph  and  the  production  of  adhesions.  Pus  widely  infiltrating 
the  cellular  or  muscular  tissues  does  not  form  an  abscess,  but  a 
phlegmon.  Pus  free  in  the  peritoneal  cavity  is  described  not  as  an 
abscess  of  the  peritoneum,  but  as  diffuse  suppurative  peritonitis. 

Two  main  varieties  of  abscess  are  recognized;  these  are  distinguished 
clinically  by  their  symptoms,  but  the  pathogenesis  of  both  is  the 
same;  they  are  the  acute  or  phlegmonous  abscess,  and  the  chronic, 
cold,  or  scrofulous  abscess.  The  former  alone  is  to  be  considered 
here;  cold  abscess  is  described  in  connection  with  surgical  tuberculosis, 
in  Chapter  III. 

Clinical  Pathology. — An  abscess  may  arise  in  any  place  where 
inflammation  exists.  It  may  be  caused  by  direct  injury  of  the  part, 
as  by  a  fall,  a  kick,  an  infected  wound,  etc.;  or  it  may  arise  second- 
arily, as  the  result  of  extension  of  inflammation  from  the  primary 
focus.  This  extension  may  occur  along  the  subcutaneous  (sub- 
peritoneal, etc.)  areolar  tissue  (causing  cellulitis),  along  the  lymphatic 
channels  (causing  lymphangeitis),  or  along  the  blood  stream  (causing 
phlebitis,  and  very  rarely  arteritis).  When  an  abscess  is  suspected 
in  a  region  which  has  not  been  directly  injured,  careful  search  should 
therefore  be  made  for  the  original  focus  of  infection;  and  it  should 
not  be  forgotten  that  the  intervening  tissues  may  show  no  evidence 
of  disease.  Thus  a  sore  on  the  foot  may  cause  inflammation  and 
eventual  suppuration  in  the  femoral  or  inguinal  lymph  nodes,  without 
any  evidences  of  lymphangeitis  of  the  leg  or  thigh.  Abscess  of  the 
liver  may  follow  appendicitis,  the  virus  of  the  disease  having  traversed 
(46) 


ABSCESS 


47 


the  radicles  of  the  portal  vein  without  leaving  evidences  of  its  passage. 
Infection  from  a  lesion  of  the  mouth  may  spread  to  the  areolar 
tissue  of  the  neck,  and  there  cause  cellulitis  and  suppuration  without 
giving  signs  of  inflammation  in  the  tissues  of  the  floor  of  the  mouth 
through  which  it  passed.  But  in  each  and  every  case,  before  suppura- 
tion can  occur,  the  earlier  stages  of  inflammation  must  have  existed 
in  the  part  in  which  the  abscess  is  ultimately  formed. 

As  the  pus  within  the  abscess  accumulates,  by  progressive  lique- 
faction necrosis  of  the  surrounding  layer  of  lymph,  the  size  of  the 
abscess  increases;  it  spreads  most  rapidly  in  the  direction  of  least 
resistance  (usually  toward  the  skin  surface),  and  pointing  of  the 
abscess  is  said  to  occur  when  the  pus  is  contained  by  the  epidermis 
alone.  Occasionally  an  abscess  will  point  and  rupture  into  a 
neighboring  cavity,  as  a  joint,  or  one  of  the  great  serous  cavities 
(pleura,  peritoneum,  etc.) ;  but  in  the  case  of  suppuration  in  internal 
organs,  sufficient  plastic  lymph  at  times  is  produced  to  confine  the 
abscess  on  its  inner  surface,  and  to  prevent  rupture  except  externally. 
When  an  abscess  is  evacuated,  the  tract  through  which  it  discharges 
is  called  a  sinus  (p.  51).  A  fistula  is  a  sinus  which  has  two  or  more 
openings;  these  may  be  on  the  skin,  or  one  may  be  on  the  skin,  another 
in  an  internal  cavity  (intestine,  joint,  urethra,  etc.),  or  both  may  be 
internal  openings  (as  in  gastro-colic,  recto-vesical,  and  other  similar 
fistula?) . 


Fig.  6. — Abscess  of  the  groin,  following  direct  injury,  one  month  previously. 
Girl,  aged  eleven  years.     Episcopal  Hospital. 

Symptoms. — At  the  onset  of  suppuration,  the  part  already  inflamed 
becomes  more  painful,  the  pain  assuming  a  throbbing  or  pulsatile 
character;  the  tenderness  is  accentuated;  the  intense  redness  of  the 
inflammation  fades  into  a  dusky  or  a  bluish  hue;  the  swelling 
becomes  better  localized;  and  frequently  the  abscess  is  seen  to 
stand  out  above  the  surface  of  the  surrounding  skin  (Fig.  6).  As 
tfye  amount  of  fluid  within  the  abscess  cavity  increases,  fluctuation, 


48 


DISEASES   RESULT1NC   Fh'uM   FX  FLA  \l)l  AT/UN 


at  first  indistinct,  becomes  unmistakable;  the  skin  over  the  abscess 
may  desquamate;  it  becomes  thinner  and  thinner,  and  finally  is 
entirely  deprived  of  its  nutrition  at  the  point  of  greatest  tension. 
A  minute  circular  slough  is  then  formed  at  this  point,  and,  when 
this  is  cast  off,  the  pus  from  within  is  discharged,  the  abscess 
cavity  is  more  or  less  obliterated  by  the  pressure  of  surrounding 
parts,  and  the  abscess  is  finally  converted  into  a  granulating 
surface.  When  suppuration  is  deeply  seated,  an  abscess  may 
attain  a  considerable  size  before  producing  such  characteristic  symp- 
toms. In  such  cases  the  overlying  skin  may  become  edematous, 
pitting  slightly  on  pressure,  owing  to  the  effusion  of  lymph  and 
serum  in  the  overlying  parts;  rigidity  and  immobility  of  the  pro- 
tecting muscles  are  important  signs;  and  the  experienced  touch  of 
the  surgeon  may  enable  him  to  proclaim  with  certainty  the  presence 
of  pus,  when  to  one  not  possessed  of  the  tactus  eruditus  a  positive 
diagnosis  would  be  impossible. 


Fig.  7. — Instruments  used  in  treatment  of  abscess:    bistoury,  eyed  probe, 
dressing  forceps,  exploring  needle. 


Diagnosis. — It  is  not  likely  that  an  acute,  superficial  abscess, 
already  pointing,  will  be  mistaken  for  anything  else.  But  there 
are  many  other  affections  with  which  an  abscess  at  times  may  be 
confused.  Careful  and  systematic  examination  of  the  patient  should 
therefore  never  be  neglected.  The  brilliant  Irish  surgeon,  Dease, 
recklessly  plunged  his  bistoury  into  a  swelling  in  the  femoral  region, 
which  he  mistook  at  first  glance  for  an  abscess,  and  his  patient  died 
before  his  eyes  from  overwhelming  and  uncontrollable  hemorrhage 
from  the  femoral  artery,  an  aneurysm  of  which  vessel  had  been  opened. 
The  diagnosis  of  an  acute  abscess  may  be  determined  by  the  history, 
by  the  local  sigjis  (fluctuation,  pointing,  etc.),  and  as  a  last  resort 
by  the  exploring  needle  (Fig.  7)  or  ordinary  hypodermic  syringe. 
Fluctuation  may  be  present  more  or  less  distinctly  in  many  other 
swellings  than  those  containing  pus;  besides  aneurysms,  effusions 
of  blood,  of  scrum,  of  urine,  etc.,  may  produce  such  fluctuating  swel- 
lings; and  cystic  and  even  fatty  and  some  other  solid  tumors  may 
give  a  similar  sensation.  The  surgeon's  fingers,  moreover,  in  pal- 
pating a  suspected  swelling,  should  be  placed  longitudinally  on  the 


ABSCESS  49 

part,  since  the  belly  of  a  large  muscle,  and  even  very  fatty  subcutaneous 
tissues  may  present  indistinct  fluctuation  if  this  point  be  neglected. 

Prognosis. — This  is  good  in  most  cases,  provided  treatment  is 
prompt  and  efficient.  But  an  abscess  may  be  dangerous  from  its 
situation,  from  its  size,  or  the  prognosis  may  be  peculiarly  grave 
from  the  constitutional  condition  of  the  patient,  or  his  age.  A 
retropharyngeal  abscess  may  cause  suffocation;  one  in  close  proximity 
to  a  large  bloodvessel  may  rupture  into  it,  and  cause  death  from 
hemorrhage  or  from  pyemia;  an  abscess  near  a  joint  may  penetrate 
its  capsule  and  cause  lasting  disability  or  even  death  from  pyar- 
throsis;  an  abdominal  abscess  may  rupture  into  the  peritoneum  and 
cause  fatal  peritonitis.  The  drain  on  the  patient's  vitality  from  a 
large  abscess,  or  from  many  smaller  abscesses,  may  lead  to  death 
from  exhaustion,  or  from  amyloid  degeneration  of  the  viscera.  In 
practically  every  case  there  will  be  loss  of  tissue,  and  a  more  or  less 
evident  cicatrix  for  years  after  the  abscess  has  healed. 

Treatment. — Much  may  be  done  to  prevent  the  formation  of  an 
abscess,  as  pointed  out  in  discussing  the  treatment  of  inflammation. 
When  pus  has  once  formed,  much  may  be  done  to  ameliorate  the 
symptoms,  and  to  cure  the  patient  with  as  little  disfigurement  as 
possible.  Though  the  process  of  pointing  can  seldom  be  hastened, 
yet  by  appropriate  treatment  the  sufferings  of  the  patient  may  be 
very  materially  relieved  until  pointing  occurs.  Heat  or  cold,  which- 
ever proves  most  grateful,  may  be  applied  locally,  and  anodynes  may 
be  administered  internally,  when  required.  Warm  moist  heat,  in 
the  form  of  a  poultice,  usually  is  most  grateful  to  the  inflamed  part. 
But  though  these  adjuvants  may  be  employed  with  advantage  in 
certain  cases,  prompt  evacuation  of  the  pus  by  incision  is  much 
more  efficient  in  checking  pain,  by  relieving  tension  and  hastening 
the  conversion  of  the  abscess  into  a  superficial  ulcer.  Moreover, 
the  cicatrix  resulting  from  a  well-placed  incision  is  much  less  dis- 
figuring than  one  which  occurs  when  an  abscess  is  allowed  to  burst 
of  itself.  In  most  abscesses  affecting  the.  subcutaneous  tissues  it  is 
better  to  postpone  incision  until  fluctuation  is  evident,  and  until 
pointing  has  nearly  occurred;  but  in  other  cases  incision  should  be 
adopted  much  earlier,  general  or  local  anesthesia  being  employed 
as  may  seem  indicated.  When  only  the  skin  intervenes  between  the 
abscess  and  the  surface  of  the  body,  no  anesthetic  is  required,  since  the 
skin  overlying  such  an  abscess  has  nearly  all  its  nerves  devitalized  by 
the  anemic  necrosis  induced  by  pressure  of  the  pus.  In  the  case  of 
deeper  abscesses,  I  much  prefer  the  hypodermic  use  of  a  local  anesthetic, 
such  as  novocain,  to  freezing  by  the  ethyl  chloride  spray;  when  the 
novocain  is  properly  used  the  entire  procedure  is  painless  except  for  the 
initial  prick  of  the  needle.  When  the  abscess  is  still  more  inaccessible, 
general  anesthesia  is  to  be  preferred,  since  in  some  instances  it  may  be 
necessary  to  undertake  a  formal  operation,  or  even  to  open  the  abscess 
across  a  serous  cavity  (pulmonary,  appendicular,  cerebral  abscess). 
In  opening  a  superficial  abscess  without  any  local  anesthesia,  the 
4 


50  DISEASES  RESULT  I  Xd  FROM   IXFLAMMATIOX 

surgeon  should  accomplisb  his  purpose  by  a  sudden  thrust  of  the 
bistoury,  which  is  held  as  a  pen,  and  with  its  cutting  edge  toward 
the  surgeon;  thus,  as  the  patient  draws  away  in  momentary  surprise 
or  pain,  the  incision  will  be  enlarged  as  the  bistoury  is  withdrawn. 
The  depth  to  which  it  is  to  be  introduced  must  be  determined  before- 
hand, and  regard  must  be  had  to  the  anatomy  of  the  part,  lest  some 
important  nerve  or  vessel  be  wounded.  In  opening  an  abscess  in  a  dan- 
gerous neighborhood  it  is  much  safer  to  adopt  Hilton's  method  (1863): 
to  incise  merely  through  the  skin  and  superficial  fascia,  and  then  to 
introduce  a  grooved  director,  and  burrow  down  to  the  abscess  with 
this,  or  with  a  dressing  forceps;  when  the  pus  is  reached,  the  blades 
of  the  forceps  are  widely  separated  and  the  forceps  is  withdrawn, 
thus  dilating  the  tract  previously  made. 

When  an  abscess  has  been  opened,  it  should  be  allowed  to  dis- 
charge itself  slowly;  the  surgeon  may  gently  support  its  sides,  to 
encourage  the  discharge  of  pus,  but  he  should  by  no  means  attempt 

to  express  it  by  massage,  and  most  em- 

9phatically  should  he  not  introduce  a 
curette  into  the  abscess  cavity  to  scrape 
away  its  lining  membrane.  Such  a  course 
destroys  the  granulation  tissue  surround- 
ing the  abscess  cavity,  may  open  neigh- 
boring venules  or  lymphatic  radicles, 
and  is  extremely  apt  to  cause  a  spread 
of  the  inflammation.  When  the  tension 
on  the  abscess  cavity  is  relieved  by  the 
evacuation  of  the  pus,  its  walls  will  col- 
lapse, and  in  the  case  of  small  abscesses 
union  between  these  apposed  walls  will 

Pig.  8. — Drainage  tube  ot  soft  -.  ,  .  \        *    -\  1         .1 

rubber,  with  numerous  eyelets.  take    place    111  a  COliple    ot    days    by    the 

process  of  secondary  adhesion  (p.  162), 
and  a  superficial  ulcer  alone  will  remain.  In  such  cases  no  drain  need  be 
introduced  into  the  abscess  cavity;  but  in  the  vast  majority  of  instances 
it  is  important  to  introduce  between  the  lips  of  the  incision  some  sub- 
stance which  will  keep  them  from  uniting  until  healing  of  the  under- 
lying abscess  cavity  is  complete.  A  tube  of  soft  rubber,  commonly 
known  as  a  drainge  tube  (Chassaignac,  1859)  (Fig.  8),  is  much  more 
satisfactory  for  this  purpose  than  is  any  substance,  such  as  gauze, 
which  may  become  clogged  with  the  discharging  pus,  and  thus  hinder, 
instead  of  promote  the  escape  of  pus  from  the  depths  of  the  cavity 
as  healing  progresses.  It  is  only  in  Arery  small  abscesses,  where  the 
discharge  is  slight,  that  a  gauze  drain  is  useful;  even  here,  a  strip  of 
rubber  tissue  is  preferable  to  gauze;  and  if  the  latter  be  employed  in 
other  cases,  where  it  may  be  of  value  by  acting  as  a  tampon  to  check 
oozing  of  blood  from  the  walls  of  the  abscess  cavity,  it  is  better  to 
use  a  tube  as  well;  or  a  cigarette  drain  (Fig.  10)  may  be  employed.  In 
small  abscesses  sufficient  drainage  may  often  be  procured  by  a  few 
strands  of  silkworm  gut. 


SINUS  AND  FISTULA 


51 


The  dressings  of  an  abscess  (gauze)  will  absorb  the  discharges 
better  if  they  are  moist.  A  solution  of  sodium  chloride,  of  corrosive 
sublimate,  of  alcohol,  of  potassium  permanganate,  or  other  suitable 
antiseptic  may  be  used  for  this  purpose.    The  gauze  immediately 


Fig.  9. — Deep  abscess  of  thigh;  through-and-through  drainage  by  rubber  tube, 
safety-pins  to  prevent  displacement  of  tube.     Episcopal  Hospital. 

next  the  discharging  sinus  should  be  well  crumpled  up  before  being 
applied;  laying  many  layers  of  flat  gauze  over  the  part  will  dam  up 
the  pus  in  the  abscess  cavity. 


Fig.  10. — Cigarette  drain,  made  by  covering  a  wick  of  gauze  with  rubber  tissue. 

Sinus  and  Fistula. — These  are  suppurating  tracts,  usually  due  to 
the  incomplete  healing  of  abscesses.  A  sinus,  as  pointed  out  at  p. 
47,  has  only  one  orifice,  since  its  other  extremity  ends  blindly  in 
the  former  abscess  cavity.1  A  fistula,  on  the  other  hand,  is  a  suppu- 
rating tract  with  at  least  two,  and  sometimes  several,  orifices,  which 
may  be  either  external,  internal,  or  both.  Sinuses  and  fistulas  may 
be  kept  from  healing  by  the  action  of  neighboring  muscles  (as  in 
fistula  in  ano);  by  the  presence  of  some  foreign  body  (spicule  of  bone, 
ligature)  which  the  tissues  of  the  organism  cannot  destroy;  or  by 
the  constant  passage  of  the  secretions  of  the  part  through  the  abnor- 
mal opening  (salivary,  fecal,  or  urinary  fistula),  instead  of  through 
the  natural  channel. 

Treatment.— They  should  be  treated  by  removal  of  the  foreign 
body;  by  removing  the  obstruction  to  the  discharge  of  the  secre- 
tions ;  or  by  supporting  the  sides  of  the  sinus  with  adhesive  plaster  or 
bandages  to  overcome  the  action  of  neighboring  muscles.  If  the  walls 
of  the  suppurating  tract  are  thickened  and  indurated,  they  should  be 
stimulated  by  the  use  of  caustic  injections  (silver  nitrate,  zinc  sulphate, 
etc.),  or  stimulating  ointments  (dilute  mercuric  nitrate,  ichthyol, 
1  Such  a  sinus  often  is  called  a  "blind  fistula." 


52  DISEASES  RESULTING  FROM  INFLAMMATION 

iodin)  on  a  rope  of  gauze;  by  curetting  the  sinus  with  Volkmann's 
sharp  spoon;  or  finally  by  slitting  the  tract  open  on  a  grooved  director, 
cauterizing  it  with  caustic  potash  or  the  actual  cautery,  thus  producing 
a  superficial  slough  and  converting  the  sinus  into  an  ulcer,  and 
promoting  healing  from  the  bottom.  In  excessively  obstinate  cases 
a  cure  may  be  obtained  by  dissecting  out  the  entire  suppurating 
tract,  and  uniting  the  parts  from  the  bottom  with  buried  absorbable 
sutures.  Some  chronic  sinuses,  especially  of  tuberculous  origin,  may 
be  cured  by  the  injection  of  a  bismuth-vaselin  paste,  as  recommended 
by  Beck  (1908)  (see  Chapter  XV). 

Ulcer. — Ulceration  is  defined  as  the  molecular  death  of  a  part. 
Some  writers  distinguish  between  an  ulcer  and  a  granulating  wound, 
limiting  the  former  term  to  the  result  of  the  process  of  destruction 
known  as  ulceration,  and  therefore  denying  that  an  ulcer,  as  such, 
can  ever  heal;  maintaining  that  as  soon  as  healing  commences  the 
term  granulating  wound  should  be  adopted.  Certain  ulcers,  however, 
may  be  granulating  at  one  portion  of  their  surface,  while  still  actively 
ulcerating  at  another  point  (serpiginous  ulceration) ;  so  it  seems  better 
while  acknowledging  the  distinction  between  ulceration  (molecular 
death)  and  granulation  (process  of  repair),  to  include  as  is  usually 
done,  both  granulating  and  ulcerating  surfaces  under  the  general 
heading  of  ulcer.  Park  (1907)  tersely  defined  an  ulcer  as  "a  surface 
which  is  or  ought  to  be  granulating." 

The  repair  of  an  ulcer  occurs  by  granulation  and  cicatrization. 
The  formerly  ulcerating  surface  gradually  loses  its  inflamed  appear- 
ance; the  discharge  of  pus  lessens;  the  edges  of  the  ulcer  become 
firmer  and  more  clearly  defined;  and  granulations  are  seen  springing 
up  all  over  its  surface.  Soon  these  granulations  become  higher  than 
the  surrounding  skin;  often  they  become  exuberant,  forming  what  is 
known  as  "proud  flesh."  Around  the  edges  of  the  ulcer  the  neighbor- 
ing epithelium  proliferates,  gradually  covering  in  the  granulations, 
and  being  easily  distinguished  as  a  faint  blue  line  interposed  between 
the  healthy  skin  and  the  face  of  the  ulcer.  Occasionally  little  patches 
of  new  skin,  with  this  same  faint  bluish  tinge,  may  be  seen  in  the 
midst  of  the  granulations,  evidently  arising  from  epithelial  cells 
which  have  survived  the  original  destructive  lesion.  As  these  changes 
progress  on  the  surface  of  the  ulcer,  beneath  its  surface  proceed  the 
changes  which  have  already  been  described  under  the  heading  Repair 
(p.  29);  that  is  to  say,  the  fibroblasts  become  converted  into  white 
fibrous  connective  tissue  (cicatrization),  and  as  a  consequence  the 
face  of  the  ulcer  contracts,  thus  decreasing  the  superficial  area  which 
must  be  covered  over  by  the  surrounding  epithelium.  This  con- 
traction, which  is  the  prime  characteristic  of  all  newly  formed 
cicatricial  tissue,  is  most  noticeable  on  the  surface  of  the  body  in 
the  healing  of  ulcers  resulting  from  burns;  and  in  mucous  channels 
(urethra,  esophagus),  where  strictures  are  the  result.  The  less  the 
infection  on  the  surface  of  the  ulcer,  the  less  will  be  the  contraction, 
and  the  more  rapidly  will  it  be  covered  by  epithelium. 


ULCER  53 

Certain  varieties  of  ulcer  are  described  by  systematic  writers. 
The  most  important  are : 

Simple  or  Healthy  Ulcer. — This  is  characterized  by  its  innate 
tendency  to  heal.  To  secure  prompt  healing  every  other  variety 
of  ulcer  must  be  converted  into  this  form.  Ordinary  incised  wounds 
healing  by  "second  intention/'  and  superficial  burns,  afford  good 
examples  of  a  healthy  ulcer.  This  ulcer,  if  not  too  large,  will  heal 
of  its  own  accord  if  it  be  protected  from  injury.  If  exposed  to  the 
air  after  the  granulations  are  well  formed,  a  scab  will  form  over  it, 
and  healing  under  the  scab  will  take  place  as  described  at  p.  162. 
Ordinarily  it  is  better  to  cover  the  ulcer  with  some  mild  ointment, 
spread  not  too  thickly  on  lint.  There  is  no  object  in  having  the 
ointment  spread  over  the  neighboring  healthy  skin  also;  indeed  to 
do  so  frequently  causes  maceration  and  delays  healing. 

Inflamed  Ulcer. — This  is  one  in  which  infection  is  still  progressing, 
the  reaction  of  the  tissues  being  insufficient  to  quell  the  invasion 
(Plate  I,  Fig.  3,  p.  66).  A  very  severe  form  of  inflamed  ulcer  is  the 
sloughing  ulcer.  The  worst  form  of  all  is  phagedenic  ulcer,  usually  seen 
only  in  chancroidal  sores;  here  the  destruction  of  tissue  is  frightfully 
rapid,  and  nothing  short  of  thorough  cauterization  of  the  entire 
ulcerated  surfaces  will  suffice  to  check  the  phagedena.  In  ordinary 
cases  of  inflamed  ulcer,  confinement  to  bed,  with  elevation  of  the 
part,  the  local  use  of  antiseptics,  and  tonics  and  stimulants  inter- 
nally, may  be  necessary  to  arrest  ulceration. 

Weak  or  Edematous  Ulcer. — This  is  characterized  by  the  granu- 
lations being  large  and  flabby,  apparently  distended  with  serum, 
of  very  low  vitality,  and  easily  detached  in  masses  from  the  sur- 
face of  the  ulcer.  Usually  it  is  an  evidence  that  proper  care  of  the 
wound  has  been  neglected,  or  that  poultices  and  mild  ointments 
(zinc  oxide  and  boric  acid)  have  been  continued  too  long.  As 
granulations  contain  no  nervous  tissue,  no  hesitation  need  be  felt 
in  snipping  off  with  scissors  the  exuberant  masses  of  proud  flesh; 
the  patient  will  not  feel  a  particle  of  pain.  Any  bleeding  is  readily 
checked  by  pressure  or  by  cauterization  with  the  stick  of  silver 
nitrate.  Then  more  stimulating  ointments  should  be  applied,  par- 
ticularly valuable  being  resin  cerate,  scarlet  red,  balsam  of  Peru, 
nitrate  of  mercury,  ichthyol,  etc. 

Neuralgic  or  Irritable  Ulcer. — This  is  usually  of  small  size,  placed 
at  the  ankle,  below  or  near  to  one  of  the  malleoli,  and  is  characterized 
by  the  intense  pain  experienced  by  the  patient.  The  skin  margins 
are  usually  thickened,  the  ulcer  has  little  or  no  discharge,  its  surface 
being  glazed  and  exquisitely  sensitive.  Frequently  it  is  evident  that 
the  ulcer  involves  the  terminal  filaments  of  some  sensory  nerve, 
especially  the  musculocutaneous  or  the  internal  saphenous  nerves 
at  the  ankle  (Fig.  11).  If  rest  in  bed,  with  elevation  of  the  part,  and 
cauterization  of  the  base  of  the  ulcer  fails  to  relieve  pain,  the 
affected  nerve  some  three  to  six  inches  above  the  ulcer  may  be 
divided  (Hilton,  1863). 


54 


DISK  ASKS   RESULTING  FROM   INFLAMMATION 


Indolent  or  Callous  Ulcer.-  This  is  the  most  frequent  form  of  "leg 
ulcer,"  usually  occurring  in  adults,  on  the  lower  half  of  the  leg,  and 
on  the  anterior  or  fibular  aspect.  The  surface  of  the  ulcer  is  dry, 
and  sometimes  glazed;  the  granulations  are  low  and  ill-formed;  the 
edges  are  hypertrophied  and  dense,  and  give  to  the  surface  of  the 
nicer  a  depressed  or  concave  appearance  (Fig.  12).  As  cure  depends 
upon  contraction  of  the  base  of  the  ulcer,  and  on  concentric  cicatri- 
zation proceeding  from  its  edges,  it  is  evident  that  destruction  of  the 
callous  margins  is  the  first  step  in  this  direction.  These  margins 
surround  the  ulcer  like  a  cartilaginous  ring,  and  by  their  lack  of 
elasticity  and  by  their  very  bulk  prevent  contraction  of  the  ulcer's 
base;  moreover,  the  surrounding  epithelium  appears  indolent  and 
unable  to  proliferate  so  as  to  cover  in  the  granulations.     The  ulcer 


Fig.  11. — Neuralgic  or  irritable  ulcer  in  a 
woman,  aged  forty-five  years.  Duration  four 
weeks.     Episcopal  Hospital. 


Fig.  12. — Indolent  or  callous  ulcers 
of  the  leg.     Episcopal  Hospital. 


usually  is  due  to  some  trivial  injury,  repair  of  which  becomes 
impossible  from  the  necessity  of  the  patients  continuing  their  occupa- 
tions as  means  of  livelihood,  and  because  of  some  constitutional 
condition  (obesity,  arteriosclerosis)  which  interferes  with  the  normal 
circulation  of  the  blood  and  lymph  in  the  part.  If  the  patient  be 
put  to  bed  and  the  callous  margins  of  the  ulcer  be  softened  by 
poultices  or  simple  wet  dressings,  the  ulcer  usually  will  soon  be  con- 
verted into  one  of  the  healthy  type,  and  cure  will  soon  be  brought 
about.  As  soon,  however,  as  the  patient  resumes  his  occupation, 
the  old  ulcer  is  apt  to  reappear  whenever  the  skin  is  bruised. 
It  is  important,  on  this  account,  to  take  great  pains  to  avoid 
injury  and  to  maintain  the  skin  in  good  condition,  when  once  the 
ulcer  has  healed.    Scrupulous  cleanliness  should   be  enjoined;  and 


ULCER 


55 


where  a  tendency  to  edema  of  the  leg  exists,  much  benefit  may 
be  gained  from  the  use  of  an  elastic  bandage,  which  usually  is 
preferable  to  an  elastic  stocking.  But  it  may  be  impossible  for 
the  patient  to  be  laid  up  in  bed  for  some  weeks,  which  is  the 
shortest  time  in  which  a  cure  may  be  anticipated;  yet  even  with- 
out the  advantages  of  rest  in  the  recumbent  position,  it  is  by  no 
means  impossible  to  bring  about  a  cure  of  the  ulcer.  Poultices  and 
wet  dressings  may  be  applied  while  the  patient  continues  at  his 
work,  and  wrhen  the  margins  of  the  ulcer  have  become  reasonably 
soft,  it  may  be  strapped  with  adhesive  plaster,  thus  supporting 
the  edges,  preventing  a  re-accumulation  of  blood  and  lymph  in  the 
parts,  and  mechanically  promoting  healing  of  the  base.  The  straps 
should  be  2.5  to  3  cm.  wide,  long 
enough  to  encircle  about  three- 
fourths  of  the  limb  when  oblique- 
ly applied;  and  are  to  be  put  on 
from  below  upward  in  an  imbri- 
cated manner,  two  at  a  time,  thus 
drawing  the  edges  of  the  ulcer  to- 
gether as  the  two  straps  are  crossed 
(Fig.  13).  The  strapping,  which 
should  start  an  inch  or  so  below 
the  ulcer,  and  continue  for  an  equal 
distance  above  its  upper  margin, 
should  be  covered  in  by  a  firm 
muslin  bandage,  extending  from  the 
patient's  toes  to  his  knee.  This 
dressing  may  remain  in  place  for 
from  five  days  to  a  week;  when  it 
is  to  be  removed,  the  skin  should 
be  washed  with  turpentine,  the 
edges  of  the  ulcer  (just  within  the 
blue  line  of  new  skin)  touched 
with  the  solid  stick  of  silver  nitrate, 
and  the  straps  again  applied  and 
covered  in  with  a  firm  bandage 
as  before.  When  the  ulcer  assumes  the  character  of  a  simple  or 
healthy  ulcer,  strapping  may  be  discontinued,  and  ointments  may 
be  applied;  but  frequently  the  ulcer  will  heal  under  the  use  of  straps 
alone.  The  results  of  this  treatment,  when  it  is  carefully  carried  out, 
are  remarkable:  ulcers  which  have  been  open  for  a  year  or  more, 
and  on  which  all  manner  of  salves  have  been  tried,  may  be  completely 
healed  within  comparatively  few  weeks.  It  is  usually  best  for  the 
patient  to  continue  to  keep  the  leg  bandaged  for  a  long  time  after 
apparent  cure  has  been  obtained,  since  relapses  are  frequent.  In 
the  rare  cases  where  rest  in  bed,  poultices,  and  strapping,  fail  to  cure 
an  indolent  ulcer,  its  conversion  into  a  healthy  ulcer  sometimes 
may  be  accelerated  by  dividing  its  callous  margin  by  several  radiating 


Fig.  13. — Strapping  a  leg  ulcer. 
Episcopal  Hospital. 


56 


DISEASES  RESULTING  FROM  INFLAMMATION 


incisions,  or  even  by  making  criss-cross  incisions  extending  through 
the  base  of  the  ulcer  and  its  callous  margin  on  both  sides.  Or  the 
ulcer  may  be  under-cut  from  the  sides,  separating  its  base  completely 
from  the  deep  fascia.  Skin  grafting  (p.  230)  has  been  employed  to 
hasten  the  cicatrization  of  these  ulcers,  but  without  much  success. 
Formal  plastic  operations  (p.  240)  occasionally  have  been  adopted, 
but  with  no  very  permanent  results.  A  great  many  of  these  callous 
leg  ulcers  are  due  to  the  unsuspected  presence  of  syphilis.  The  typical 
syphilitic  leg^  ulcer  (Fig.  14)  is  situated  above  the  middle  of  the  leg, 
is  characteristically  round,  is  seldom  very  painful,  and  yields  with 


Fig.  14. — Syphilitic  ulcer  of  leg,  mule, 
aged  twenty-four  years.  Following  "ru- 
pia"  of  six  weeks' duration.  Completely 
healed  under  anti-syphilitic  treatment  in 
three  weeks.     Episcopal  Hospital. 


Fig.  15. — Varicose  leg  ulcer. 
Episcopal  Hospital. 


remarkable  facility  to  the  administration  of  mercury  and  the  iodides. 
But  in  many  of  the  callous  ulcers  in  which  no  definite  history  of 
syphilis  can  be  obtained,  much  improvement  often  follows  the  adminis- 
tration of  potassium  iodide  alone  or  with  mercury.  In  almost  all 
cases  of  leg  ulcer  of  long  duration  the  tibia  immediately  beneath 
the  seat  of  disease  becomes  thickened;  but  in  the  case  of  syphilitic 
ulcers  there  is  sclerosis  of  the  bones,  and  as  pointed  out  by  Coues 
the  diagnosis  of  syphilitic  leg  ulcer  usually  may  be  confirmed  by  a 
skiagraph.  In  very  exceptional  cases  the  callous  ulcer  is  absolutely 
incurable.    But  life  with  an  incurable  leg  ulcer  is  by  no  means  impos- 


GANGRENE 


bi 


sible;  indeed,  many  persons  live  for  fifteen  to  twenty  years,  or  longer, 
with  unhealed  leg  ulcers,  and  are  able  to  lead  very  active  lives.  It 
is  only  in  the  rarest  instances,  therefore,  that  amputation  is  justi- 
fiable; for  the  risk  to  life  usually  is  much  less  from  an  unhealed  leg 
ulcer  than  from  amputation. 

Varicose  Ulcer. — This  is  one  associated  with  varicose  veins  (Fig.  15). 
It  is  difficult  to  heal,  sometimes  is  attended  by  alarming  hemorrhages, 
and  frequently  incapacitates  the  patient.  The  use  of  elastic  bandages, 
hot  baths,  gentle  massage,  etc.,  by  reducing  the  swelling,  and  improv- 
ing the  circulation  of  the  limb,  sometimes  will  bring  about  a  cure, 
or  at  least  will  keep  the  patient  in  comfort.  Bed  treatment  is  better. 
If  palliative  measures  fail,  excision  of  the  affected  veins  may  be  done 
and  often  the  ulcer  heals;  but  the  operation  is  one  of  more  risk  than 
when  no  ulcer  exists,  and  should  not  be  undertaken  lightly.  It  should 
never  be  done  in  the  presence  of  active  phlebitis;  and  if  the  veins 
are  thrombosed  as  the  result  of  a  former  phlebitis,  they  should  be 
divided  through  healthy  portions  above  the  limit  of  the  clot.  Homans 
(1917)  urges  excision  of  the  ulcer  whenever  the  deep  veins  are  involved. 

Warty  Ulcer.— Under  this  name  Marjolin  (1846)  described  a  form 
of  ulcer  which  of  late  years  usually  has  been  regarded  as  due  to 
malignant  changes.  It  is  not  correct,  how- 
ever, to  give  the  name  of  Marjolin  to  every 
ulcer  which  undergoes  malignant  transfor- 
mation, as  his  original  description  applied 
merely  to  the  clinical  appearance  of  the  ulcer, 
as  if  covered  with  warts.  Fig.  16  represents 
a  typical  warty  ulcer,  which  healed  rapidly 
under  appropriate  treatment.  When  of  long 
standing  a  malignant  ulcer  whose  surface  is 
warty  frequently  is  found  to  involve  the 
bone,  which  is  the  seat  of  caries,  perhaps  due 
to  a  primary  sarcoma  of  bone,  or  possibly 
involved  secondarily  by  a  surface  epithelioma. 
If  the  warty  ulcer  is  malignant,  it  is  much 
safer  to  amputate  the  limb  than  to  attempt 
excision;  but  if  the  malignant  ulcer  is  of  the 
heel  (I  have  seen  two  cases  following  burns 
in  this  situation),  resection  may  properly  be 
done,  with  restoration  of  the  foot  by  the 
method  of  Mikulicz,  if  the  patient  refuses 
amputation. 

Gangrene  (sphacelus,  mortification,  slough- 
ing) is  a  term  used  to  describe  the  process 
of  death  of  the  soft  parts,  or  of  an  entire 
extremity  with  its  contained  bone,  when  this  death  occurs  in  mass; 
necrosis,  though  usually  confined  in  its  application  to  death  of  bone,  is 
occasionally  employed  to  describe  the  death  of  soft  parts  at  a  depth 
from  the  surface,  where  no   marked    inflammatory   phenomena   are 


Fig.  1G. — Warty  ulcer  of 
Marjolin  connected  with 
periosteitis  eight  months 
after  typhoid  fever.  From 
direct  injury.  Aged  fourteen 
years.    Episcopal  Hospital. 


r,s 


DISEASES  RESULTING  FROM  INFLAMMATION 


present,  the  resulting  necrotic  masses  corresponding  very  closely  to 
the  sequestra  met  with  in  necrosis  of  hone.  In  ulceration,  the  dead 
parts  are  casl  off  in  the  form  of  pus  (liquefaction  necrosis),  and 
molecular  death  of  the  tissues  is  said  to  occur;  whereas  in  gangrene 
(molar  death)  the  parts  cast  off  (sloughs)  are  of  such  size  as  to  be 
clearly  visible  to  the  naked  eye. 

The  causes  of  gangrene  are  either  direct  (as  in  pulpefaction  of  a 
limb  by  crushing  force,  destruction  by  caustics,  by  heat  or  cold,  by 
bacterial  toxins,  etc.),  or  indirect,  from  interference  with  the  vascular 
supply.    One  of  the  most  extensive  cases  of  sloughing  I  ever  saw  was  in 

a  lad  of  sixteen  years,  whose  whole  lowTer 
extremity  had  passed  through  cog-wheels; 
though  there  was  no  injury  to  the  vascu- 
lar supply  of  the  limb,  the  pressure  of  each 
cog  produced  immediate  death  of  the  area 
it  crushed,  and  it  was  over  ten  weeks  he- 
fore  the  sloughs  had  all  separated  and  the 
resulting  ulcers  healed.  The  appearance 
of  the  cicatrices  six  years  after  the  accident 
is  shown  in  Fig.  17.  Injuries  which  in  a 
normal  state  of  health  would  cause  only 
trivial  lesions,  when  complicated  by  vascu- 
lar obstruction  or  constitutional  disease 
may   result  in   very  extensive   sloughing 


Fig.  17. — Cicatrices  from 
sloughing,  six  years  after  in- 
jury (cog-wheels).  Episcopal 
Hospital. 


Fig.  18. — Gangrene  following  application  for 
twenty-four  hours  by  patient's  mother  of  carbolic 
acid  dressing.     Episcopal  Hospital. 


or  gangrene.  The  same  degree  of  inflammatory  infiltration,  which  in 
the  subcutaneous  tissues  wTould  be  harmless,  when  occurring  beneath 
the  palmar  fascia  or  other  dense  fibrous  membrane  may  produce  such 
a  choking  off  of  the  blood-supply  as  to  cause  extensive  necrosis  of  the 
structures  involved.  In  the  old,  or  in  younger  persons  with  marked 
arteriosclerosis,1  so-called  senile  gangrene  may  follow  trifling  injuries, 
or  may  be  caused  by  gradual  occlusion  of  the  arteries  without  external 
injury.  In  diabetics  there  is  a  special  tendency  to  necrotic  processes, 
among  the  mildest  of  which  are  furuncles  with  their  central  slough  or 
core.  In  patients  suffering  from  ergotism,  gangrene  of  the  fingers  or 
1  This  is  what  Buerger  (1908)  has  called  thrombo-angeitis  obliterans. 


SYMPTOMS  OF  GANGRENE  59 

toes,  perhaps  symmetrical,  is  a  not  infrequent  phenomenon.  It  is  usually 
preceded  by  premonitory  symptoms,  such  as  formication,  cramps, 
local  asphyxia,  etc.  Certain  lesions  of  the  nervous  system,  probably 
through  vaso-motor  changes,  may  induce  bed-sores,  sloughing,  etc., 
in  an  alarmingly  short  space  of  time.  The  so-called  perforating  ulcer 
of  the  foot  (p.  291),  probably  is  due  to  a  similar  change,  though 
arteriosclerosis  is  usually  a  factor  also.  Carbolic  acid  gangrene 
(Fig.  18)  results  from  the  direct  caustic  action  of  the  solution 
employed,  and  often  follows  the  use  of  a  weak  solution  which 
becomes  concentrated  by  evaporation. 

Bacteria  are  not  a  necessary  accompaniment  of  gangrene;  their 
presence  usually  is  incidental.  In  a  few  rare  instances,  bacterial 
toxins  are  believed  to  be  the  immediate  cause  of  gangrene  by  causing 
endarteritis,  phlebitis,  and  thrombosis.  This  is  probably  the  case 
in  noma  (p.  62).  Emphysematous  gangrene  (p.  88)  is  due  to  infec- 
tion with  gas-producing  bacteria,  the  production  of  gas  preceding 
the  development  of  gangrene.  Saprophytic  bacteria  usually  invade 
tissues  which  have  already  become  gangrenous,  and  produce  the 
malodorous  gases  characteristic  of  putrefaction. 

There  are  two  main  varieties  of  gangrene,  the  moist  and  the  dry, 
dependent  in  large  measure  upon  the  amount  of  moisture  in  the 
part  when  the  vascular  current  is  occluded,  and  on  the  amount  of 
evaporation  which  takes  place.  Moist  gangrene  usually  is  due  to 
venous  obstruction  (thrombosis,  pressure  of  tumors,  splints,  bandages, 
etc.);  it  is  occasionally  seen,  however,  after  sudden  occlusion  of  the 
main  artery  of  a  limb  (embolism,  wounds,  ligation,  etc.),  if  the  venous 
blood  already  present  remains  in  the  part.  Dry  gangrene,  of  which 
the  senile  form  is  typical,  usually  is  due  to  slowly  progressing  arterial 
occlusion,  the  parts  deprived  of  vascular  supply  becoming  mummi- 
fied.   Diabetic  gangrene  is  usually  rather  dry. 

Symptoms. — When  a  part  which  has  been  inflamed  becomes  gan- 
grenous, the  color  fades  into  bluish  green  or  purple,  and  finally  into 
black;  the  pain,  at  first  burning  and  intolerable,  suddenly  ceases; 
the  affected  area  becomes  numb  and  senseless;  the  cuticle  is  raised  in 
bullae  filled  with  bloody  or  purulent  fluid;  the  part  instead  of  being 
tense  feels  doughy;  and  the  local  temperature  falls.  There  is  gradually 
formed,  at  the  point  where  the  resistive  powers  of  the  individual 
are  sufficient  to  overcome  the  destructive  lesions  producing  the 
gangrene,  a  line  of  demarcation,  indicated  by  a  red  line  encircling 
the  gangrenous  structures.  In  this  region  the  usual  phenomena  of 
inflammation  occur,  and  as  this  process  continues,  a  line  of  granula- 
tions is  formed,  known  as  the  line  of  separation.  By  the  gradual 
increase  of  these  granulations  the  dead  tissues  are  pushed  away,  as 
it  were;  and  unless  assisted  by  the  surgeon  this  tedious  process  will 
continue  until  the  entire  gangrenous  area  is  extruded  in  the  form  of  a 
slough.  An  entire  limb  may  be  amputated  spontaneously  in  this 
way. 

During  the  formation  of  the  line  of  demarcation,  there  is  often 


60  DISEASES  RESULTING  FROM   INFLAMMATION 

considerable  constitutional  disturbance1,  due  to  the  sapremia  caused 
by  absorption  from  the  imperfectly  isolated  gangrenous  area;  and 
even  during  the  process  of  granulation,  before  the  slough  is  cast  off, 
the  patient  is  constantly  exposed  to  infection  from  the  decayed  struc- 
tures. These  constitutional  symptoms  usually  are  much  less  or 
altogether  absent  in  dry  gangrene,  where  the  process,  as  already 
mentioned,  resembles  mummification. 

Treatment/ — The    separation    of    sloughs    sometimes    seems    to   be 
hastened  by  poulticing  the  part.    The  charcoal  poultice  is  particularly 
useful  in  these  cases,  as  it  lessens  the  odor  by  absorbing  the  gases. 
The    yeast    poultice    also    acts   well.     Various    chemical    digestants, 
especially,  of  late,  Dakin's  fluid  (see  p.  170),  have  been  used,  in  the 
effort  to  aid  nature  in  dissolving  the  sloughs;  but  little  more  is  thus 
accomplished  than  by  simply  keeping  the  parts  clean  and  protect- 
ing them  from  outside  infection.     In  the  case  of  extensive  gangrene, 
the  most  important  thing  is  to  prevent  infection;  amputation  will 
surely  be  required  later,  but  if  infection  is  absent  the  surgeon  can 
safely  postpone  it  until  some  indication  is  present  of  the  level  at 
which    it    must    be    done.     Early    amputation    is    often    needlessly 
high.     In  moist  gangrene  constant  exposure  to  the  sun  or  electric 
light    is    one    of    the    surest    methods    of    preventing    infection;    in 
dry  gangrene  it  usually  is  sufficient  to  keep  the  parts  well  covered 
with  sterile  cotton.     Periodical  baking  of  the  limb,  as  in  chronic 
joint  affections,  is  also  of  great  service.     In  senile  gangrene,  where 
only  one  or  two  toes  are  affected,  formal  amputation  may  never  be 
required,  as  nature  will  be  able  to  remove  the  slough  at  one  of  the 
phalangeal  joints  with  less  constitutional  disturbance  than  would  be 
caused  by  an  operation ;  if  the  gangrene  extends  beyond  the  toes,  how- 
ever, amputation  should  be  done  above  the  ankle;  and  if  it  extends 
above  the  ankle,  amputation  through  the  lower  third  of  the  thigh 
should  be  done:  it  is  not  advisable  to  wait  for  the  line  of  demarcation, 
and  to  amputate  at  lower  points  than  those  named  almost  certainly 
would  expose  the  patient  to  recurrence  of  gangrene  in  the  stump. 
To  determine  the  level  at  which  amputation  should  be  done  Lejars 
employs    (1909)    the   " comparativehy  peremia"    test:    the    limb    is 
elevated,  an  elastic  bandage  is  applied,  exsanguinating  it,  and  exsan- 
guination  is  maintained  by  an  Esmarch  band  for  five  or  ten  minutes 
after  the  elastic  bandage  is  removed;  the  hyperemic  blush  which 
follows  the  removal  of  the  Esmarch  band  will  extend  only  so  far 
as  healthy  circulation  is  present,  and  amputation  may  be  done  safely 
at  this  point.    In  the  healthy  limb  the  hyperemic  blush  extends  to 
the   toes.     In   all  cases,   particularly  of    pre-senile   gangrene,   large 
quantities  of  fluid  should  be  introduced  into  the  system.     In  many 
cases   of  senile   gangrene   it   is  evident  that  any    operation   would 
only  hasten  the  fatal  termination;  under  such  circumstances  of  course 
only  palliative  treatment  is  admissable.    In  diabetic  gangrene  (Fig.  19) 
amputation  is  not  to  be  recommended  until  sepsis  threatens.    De  Witt 
Stetten    (1912)   has  shown    the   remarkable   success  which   attends 


SPECIAL  FORMS  OF  GANGRENE 


01 


Fig.  19. — Diabetic  gangrene.  Aged 
seventy-four  years.  Duration  two 
months.  Healed  under  conservative 
treatment.       Episcopal    Hospital. 


judicious  conservative  treatment,  especially  sterilization  of  the  limb 
by  repeated  baking.  In  the  only  successful  cases  I  have  had,  ampu- 
tation has  been  postponed  until 
the  patients  had  become  "sugar 
free"  and  were  again  able  to  take 
moderately  full  diet.  Amputation 
for  gangrene  following  frost-bite  and 
burns,  should  not  be  done  until  the 
line  of  demarcation  has  formed,  as 
it  is  impossible  to  know  beforehand 
at  what  level  the  limb  must  be 
removed.  In  the  case  of  gangrene 
resulting  from  local  injury  due  to 
crushes,  compound  fractures,  etc., 
amputation  should  be  done  as 
soon  as  gangrene  is  manifest;  it 
is  impossible  to  prevent  infection 
in  such  cases,  and  delay  in  resort- 
ing to  amputation  usually  will  cost 
the  patient  his  life.  When  gan- 
grene is  due  to  arterial  occlusion 
(embolism,  ligation  for  wound), 
amputation  should  be  done  at  the 
site  of  the  occlusion,  as  soon  as 
gangrene  is  evident  (Guthrie,  1815);  but  in  the  case  of  injury  to  the 
superficial  femoral  artery,  amputation  below  the  knee  usually  is  suffi- 
cient, and  occasionally  in  the  upper  extremity  a  collateral  circulation 

may  be  established,  so  that 
here  it  may  be  justifiable 
to  await  the  formation  of 
a  line  of  demarcation,  un- 
less sepsis  threatens. 

Special  Forms  of  Gan- 
grene.—Decubitus  or  Bed- 
sore (Fig.  21)  is  due  to 
necrosis  of  the  skin  and 
subcutaneous  tissues  from 
long  continued  pressure  on 
bony  prominences  in  those 
confined  to  bed,  especially 
in  those  with  debilitating 
diseases  or  in  a  helpless 
condition.  Favorite  sites 
are  over  the  sacrum  and 
fsacro-iliac  joints  (Fig.  22) ; 
but  any  point  receiving  constant  pressure  (occiput,  scapulae,  elbows, 
heels,  malleoli)  may  develop  bed-sores.  They  usually  may  be  pre- 
vented by  proper  care  of  the  skin,  allowing  no  folds  or  creases  in  the 


Fig.  20. — Dry  gangrene  from  embolism;  male, 
aged  forty  years.  In  December  embolus  lodged  in 
brain,  causing  right-sided  hemiplegia;  in  March 
(three  weeks  before  photograph)  embolus  lodged  in 
right  popliteal  artery.  Death  a  few  weeks  later. 
No  operation.     Episcopal  Hospital. 


G2 


DISEASES  RESULTING  FROM  INFLAMMATION 


bed-clothes  (the  patient  may  lie  on  a  blanket  instead  of  a  sheet),  with 
frequent  changes  of  position,  and  use  of  air-pillows,  rings,  water-beds, 
etc.  Scrupulous  cleanliness  is  most  important,  keeping  the  skin  dry 
(in  cases  of  involuntary  dejections)  and  protecting  it  after  use  of  stimu- 
lating lotions  by  dusting  powders  or  soap  plaster.  The  same  measures 
are  important  in  the  treatment  of  a  bed-sore  when  once  it  has  formed. 
The  slough  should  not  be  cut  away  until  it  is  quite  loose.  Healing  may 
be  hastened  by  exposure  of  the  ulcer  to  direct  sunlight,  gradually  length- 
ening the  exposures;  or  by  nearly  constant  exposure  to  electric  light. 
Constitutional  treatment  never  should  be  neglected.  Get  the  patient 
out  of  bed  as  soon  as  possible.  Long  continuance  of  a  large  bed-sore 
is  a  tremendous  drain  on  the  vitality  and  not  infrequently  is  an 
indirect  cause  of  death  (exhaustion,  sepsis,  hemorrhage). 


Fig.  21. — Decubitus  or  bed-sore,  in  a 
patient,  aged  seventy-eight  years;  duration 
two  months.  The  sloughs  have  been  cut 
away.     Episcopal  Hospital. 


Fig.  22. — Cicatrices  from  bed- 
sores, in  patient,  aged  twenty  years, 
developing  during  typhoid  fever  five 
years  ago.     Episcopal  Hospital. 


Hospital  Gangrene  {Sloughing  Phagedena,  Pourriture  d'Hopital). — 
This  scourge  of  military  hospitals  in  former  years  is  due,  according  to 
Vincent,  to  a  specific  "fusiform  bacillus."  Its  clinical  causes  are 
crowding,  bad  ventilation  and  generally  unhygienic  conditions.  It 
is  now  almost  unknown.  Only  a  very  few  cases  appear  to  have 
occurred  during  the  German  War.  It  arises  only  in  wounds,  though 
the  wounds  sometimes  are  mere  abrasions.  The  surface  of  the 
wound  becomes  dry,  is  covered  with  "a  pulpy,  ashen  slough,"  and 
the  circular  shape  and  cup-like  depression  of  the  wound  are  con- 
sidered characteristic.  By  attention  to  hygiene,  its  development 
usually  may  be  prevented.  It  is  most  successfully  treated  by  strong 
antiseptics  (bromin,  iodin)  and  scrupulous  cleanliness.  Patients 
affected  should  be  isolated.    Amputation  is  scarcely  ever  necessary. 

Noma. — Noma  is  a  gangrenous  affection,  almost  exclusively  con- 
fined to  childhood,  usually  following  the  exanthemata  (especially 
measles)  or  typhoid  fever,     Various  bacteria  have  been  found  by 


AINHUM 


63 


different  observers,  certain  forms  of  leptothrix  being  those  most 
frequently  present.  As  mixed  infection,  including  saprophytes, 
almost  always  exists,  the  etiological  relation  of  any  one  form  is  diffi- 
cult to  determine.  The  disease  affects  the  mouth  {Gangrenous 
Stomatitis,  Cancrum  Oris)  and  the  external  genitals  (Noma  Pudendi), 
especially  the  genitals  of  female  children.  The  ear  and  the  rectum 
have  also  been  affected.  Whether  in  the  mouth  or  the  genitals,  the 
disease  usually  starts  on  the  mucous  membrane,  and  in  an  incredibly 
short  space  of  time,  perhaps  three  or  four  hours,  a  gangrenous  ulcer 
3  cm.  or  more  in  diameter,  may  be  present.  The  first  thing  to  attract 
attention  is  often  a  shiny  red  spot  on  the  exterior  of  the  cheek,  the 
gangrenous  ulcer  having  nearly  perforated  before  being  discovered. 
But  if  this  complication  be  kept  in  mind  the  disease  may  be  detected 
at  an  earlier  stage  from  fetor  of  the  breath,  disinclination  for  food, 
etc.,  which  will  lead  the  nurse  or  attending  physician  to  examine 
the  mouth.  The  constitutional  symptoms  are  slight,  and  the  child, 
though  listless,  may  continue  to  play  with  its  toys  until  the  hour 
of  death.  The  alveolus  may  be  involved,  the  cheek  perforated,  and 
frightful  destruction  produced  in  a  very  short  space  of  time. 

Treatment  should  be  prompt  and  vigorous;  the  child  being  anesthe- 
tized, a  mouth  gag  should  be  introduced,  the  cheek  everted,  scraped 
with  Volkmann's  spoon,  and 
the  base  of  the  ulcer  thoroughly 
cauterized  with  fuming  nitric 
acid  applied  by  a  stout  stick; 
or  acid  nitrate  of  mercury  may 
be  used.  If  the  cheek  has  been 
perforated,  it  is  best  to  exer- 
cise the  whole  ulcer;  and  it 
may  be  necessary  to  excise 
a  portion  of  the  alveolus 
(Fig.  23).  Free  stimulation 
must  be  employed  afterward 
and  the  mouth  kept  constantly 
clean  by  the  use  of  suitable 
washes.  Death  from  exhaus- 
tion, bronchopneumonia,  or 
pyemia,  is  the  rule.  The  mor- 
tality varies  from  70  to  95  per  cent.  If  the  child  recovers,  a  plastic 
operation  may  be  necessary  to  restore  the  cheek.  Similar  treatment 
should  be  adopted  in  the  case  of  Noma  Pudendi,  which  is  a  much 
rarer  affection. 

Ainhum. — This  is  a  rare  tropical  disease,  generally  ending  in 
gangrene,  which  usually  is  dry,  affects  the  toes,  and  is  almost  exclu- 
sively confined  to  the  negro  race.  Unna,  according  to  Freeman 
(1906),  regards  it  as  a  circular  scleroderma  which  strangulates  the 
toe.  The  affected  parts  appear  as  if  tightly  constricted  by  a  string, 
and  spontaneous  amputation  occurs  after  the  lapse  of  an  indefinite 
time.    The  disease  may  extend  over  ten  years. 


Fig.  23. — Noma  following  measles,  in  a 
child,  aged  three  years;  duration  one  week. 
The  gangrenous  parts  have  been  excised. 
Death.     Children's  Hospital. 


<;i 


DISFASFS   RESULTING  FROM   INFLAMMATION 


Symmetrical  Gangrene.  —Symmetrical  gangrene  is  due  to  an  obscure 
affection  of  the  nervous  system  (Raynaud's  disease),  causing  local 
asphyxia  of  symmetrical  portions  of  the  body,  especially  ringers 
and  toes,  probably  from  vascular  spasm.  As  a  rule  only  small  super- 
ficial sloughs  are  formed.  The  symptoms  are  tingling,  numbness, 
etc.  Intermittent  claudication  may  be  an  early  sign.  Little  can 
be  done  in  the  way  of  treatment,  except  tonics  and  hygienic  measures. 
Massage  and  hot  baths,  locally,  may  be  of  benefit.  The  patients 
usually  recover,  though  successive  attacks  are  usual.  Noesske  (1909) 
incises  the  finger  tip  down  to  the  bone  and  applies  a  cupping  glass; 
his  theory  is  that  the  gangrene  is  due  to  stagnation  of  blood  from 
venous  obstruction;  and  that  if  a  constant  fresh  supply  of  arterial 
blood  is  obtained  by  cupping,  gangrene  may  be  prevented  until  the 
spasm  ceases.     Fluids  may  be  introduced  through  a  duodenal  tube. 

Gas  Gangrene. — See  p.  88. 

Cellulitis.  —  Cellulitis  is  the  term  used  to  describe  inflammation 
of  the  subcutaneous  areolar  tissue.  This  tissue,  it  is  known,  consists 
essentially  of  lymph  spaces  lined  by  endo- 
thelial or  connective  tissue  cells;  and  it  is 
now  generally  believed  that  these  spaces 
have  no  direct  communication  with  the 
lymph  vascular  system.  Certainly  cellu- 
litis, as  such,  is  clearly  distinguished  from 


Fig.  24. — Suppurative  cellulitis  of  right  forearm, 
eleven  days'  duration.  From  infected  wound  of  wrist. 
Incised  and  drained  through  interosseous  membrane. 
Children's  Hospital. 


Fig.  25. — Scars  from  multi- 
ple incisions  for  cellulitis  of 
calf.    Episcopal  Hospital. 


lymphangeitis  on  the  one  hand,  and  from  infectious  dermatitis  on  the 
other.  The  causes  are  almost  without  exception  bacterial  infection, 
streptococcic  rather  than  staphylococcic,  usually  from  some  abrasion 
or  lacerated  wound;  but  occasionally  cellulitis,  extending  to  the  stage 
of  suppuration,  follows  a  contusion,  a  sprain,  or  a  simple  fracture, 


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ERYSIPELAS  65 

the  infection  in  such  cases  being  conveyed  to  the  place  of  lessened 
resistance  through  the  blood-stream.  Cellulitis  may  also  follow  extra- 
vasation of  urine,  of  blood,  etc. 

Symptoms. — The  symptoms  are  those  of  inflammation,  widely 
diffused  beneath  the  skin,  not  in  it,  and  characterized  especially  by 
swelling,  pitting  on  pressure,  and  the  absence  of  marked  redness 
(Fig.  24). 

Treatment. — In  the  early  stages  rest  procured  by  splints,  by  the 
use  of  a  sling,  by  elevation  of  the  part,  together  with  local  anodyne 
(lead  water  and  laudanum)  and  antiseptic  (corrosive  sublimate  and 
alcohol)  applications  after  proper  opening  of  the  focus  of  infection, 
may  suffice  to  effect  a  cure.  As  soon  as  evidences  of  suppuration 
occur,  the  overlying  skin  should  be  incised,  in  as  many  places  as  may 
be  necessary,  to  give  exit  to  pus,  sloughs,  etc.  If  the  part  affected  is 
very  tense,  as  is  frequently  the  case  in  the  forearm  and  hand,  it  is 
advisable  to  make  free  longitudinal  incisions  even  before  pus  is  formed, 
as  the  relief  of  pressure  will  enable  the  body  tissues  to  combat  the 
infection  much  more  readily,  and  may  prevent  extensive  sloughing. 
Fig.  25  shows  the  scars  of  multiple  incisions  for  cellulitis  of  the  leg. 

Erysipelas. — Erysipelas  (a  word  usually  supposed  to  be  derived 
from  two  Greek  words  signifying  red  skin),  known  formerly  as  St. 
Anthony's  Fire,  is  a  specific  inflammation  affecting  the  skin,  the 
subcutaneous  tissues,  or  both.  Occasionally  the  mucous  or  serous 
membranes  are  involved.  It  is  a  specific  disease  clinically;  and 
according  to  some  authorities  its  cause,  the  Streptococcus  erysipelatis 
(Fehleisen,  1884),  is  specific,  in  the  sense  that  it  causes  no  other 
disease;  but  equally  good  authorities  maintain  that  it  is  not  a 
specific  microbe,  but  merely  a  variety  of  the  common  streptococcus, 
which  for  some  unknown  reason  at  certain  times  does  not  produce 
the  usual  symptoms.  The  seat  of  the  inflammation  is  the  lymphatic 
spaces  of  the  skin  itself  (dermatitis)  and  of  the  subcutaneous  tissues 
(cellulitis.) 

Erysipelas  probably  always  is  due  to  the  presence  of  a  solution 
of  continuity  of  the  skin  or  mucous  membrane,  through  which  the 
bacteria  enter  the  tissues;  but  while  it  is  not  extremely  rare  in  patients 
with  lacerated  wounds  and  compound  fractures,  it  arises  much  more 
often  as  the  so-called  idiopathic  variety,  in  which  the  wound  probably 
is  some  insignificant  abrasion.  Especially  is  this  the  case  with  facial 
erysipelas,  one  of  the  most  prevalent  forms,  the  wound  of  entrance 
being  probably  some  excoriation  of  the  nasal  mucous  membrane. 
The  eruption  is  characterized  by  its  intense  redness,  which  returns 
immediately  on  the  removal  of  pressure;  by  its  glazed  or  shiny  surface; 
frequently  by  vesiculation;  by  the  raised,  irregular,  and  well-defined 
borders  of  the  inflamed  area;  and  by  the  erratic  manner  in  which  it 
spreads  (Plate  I,  Fig.  2).  The  inflammation  is  always  most  intense 
at  the  periphery  of  the  patch,  while  the  center  may  begin  to  fade 
away  very  quickly.  In  simple  erythema  the  patches  have  no  ten- 
dency to  spread,  their  edges  are  not  raised,  and  vesiculation  is 
5 


06 


DISEASES  RESULTING  FROM  INFLAMMATION 


unknown.  In  scarlatina  the  rash  is  not  localized,  it  is  neither 
well  defined  nor  are  its  margins  elevated  above  the  surrounding 
skin;  vesiculation  is  absent;  it  is  a  rare  disease  in  adults;  and  a 
history  of  contagion  may  be  obtainable.  The  dermatitis  resulting 
from  Rhus  Toxicodendron  is  very  difficult  to  distinguish  from  ery- 
sipelas, except  by  the  history;  the  same  is  true  of  saprophytic 
dermatitis  (erysipeloid  of  Roscnbach),  due  to  local  infection  from 
decaying  fish,  etc.  In  ordinary  cellulitis  the  redness  is  less,  and 
the  raised  margins  and  vesicles  of  erysipelas  are  absent;  and  as  the 
skin  itself  is  not  involved  in  cellulitis  the  disease  does  not  affect 
the  ears  nor  usually  the  skin  over  the  tip  of  the  nose,  in  which 
situations  subcutaneous  tissue  is  practically  absent.  In  erysipelas, 
on  the  other  hand,  the  pinna  of  the  ear  is  prone  to  invasion. 


\ 

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Fig.  26. — Temperature  chart  of  erysipelas  developing  in  a  case  of  cellulitis  of  the  leg. 

(Episcopal  Hospital.) 

Symptoms. — The  subjective  symptoms  are  marked:  these  are  pain, 
tingling,  and  a  feeling  of  tension  in  the  affected  parts,  which  are 
exquisitely  tender;  there  is  a  sudden  rise  of  temperature  to  a 
high  point  (Fig.  26),  rapid  pulse,  furred  tongue,  often  delirium, 
and  occasionally  nausea,  vomiting  and  chills.  As  a  rule  there  are 
no  prodromal  symptoms  of  importance.  The  eruption  seldom 
lasts  more  than  four  days  in  one  spot;  from  the  original  focus 
it  may  wander  irregularly  over  the  body,  or  may  break  out  in  an 
entirely  different  region.  As  the  inflammation  subsides,  the  skin 
becomes  brownish  in  hue,  the  vesicles  dry  in  the  form  of  scabs,  and 
the  part  appears  more  or  less  wrinkled.  In  facial  erysipelas  edema 
is  marked,  the  eyes  being  closed  and  the  nose  and  ears  swollen 
beyond  all  recognition.  There  is  a  tendency  for  the  disease  to  spread 
to  the  scalp;  here  the  redness  is  less,  and  the  general  characteristics 
of  cellulitis  are  more  evident. 

Complications. — In  facial  erysipelas  there  is  always  a  danger  of 
meningitis,  from    involvement    of  the    angular    vein  or    one    of  the 


GENERAL  AFFECTIONS  RESULTING  FROM  INFLAMMATION     67 

emissary  veins  of  the  skull.  Nephritis  may  result  from  the  strain 
put  upon  the  kidneys  in  the  elimination  of  toxins.  Endocarditis, 
pleurisy,  pneumonia,  peritonitis,  arthritis,  and  general  septicemia 
occasionally  are  observed.  Phlegmonous  erysipelas,  so-called,  is 
streptococcic  inflammation  of  the  cellular  tissues  accompanying 
erysipelas  of  the  skin.  If  the  erysipelatous  inflammation  invades 
the  fauces  (angina),  or  the  larynx,  producing  edema  of  the  glottis, 
laryngotomy  may  be  necessary. 

Prognosis.  —  Erysipelas  is  a  serious  disease,  though  seldom  the 
direct  cause  of  death.  S.  Erdman  (1913)  gives  the  hospital  mor- 
tality as  11  per  cent.  One  attack  seems  to  predispose  the  patient  to 
recurrence. 

Treatment. — When  occurring  in  a  hospital  ward,  cases  of  erysipelas 
should  be  isolated;  for  although  contagion  through  the  air  has  not 
been  known  to  occur,  the  infection  of  other  patients  by  contact 
cannot  always  be  prevented.  The  surgeon  who  dresses  the  wounds 
of  an  erysipelatous  patient  should  not  practice  obstetrics  while  so 
engaged.  O.  W.  Holmes  (1843)  long  ago  called  attention  to  the 
relation  between  erysipelas  and  puerperal  fever.  Constitutional 
treatment  is  to  be  given  only  as  indicated;  stimulants  and  tonics, 
especially  the  tincture  of  the  chloride  of  iron  or  quinin,  are  usually 
of  benefit;  a  purge  at  the  onset  of  the  attack  may  do  much  to  hasten 
its  disappearance.  In  the  way  of  local  treatment  very  little  can 
be  done  that  is  really  productive  of  any  marked  benefit.  Ichthyol 
ointment  has  been  much  used,  and  is  agreeable  to  the  patient.  A 
saturated  solution  of  magnesium  sulphate  is  claimed  by  some 
(Tucker,  1908)  to  have  almost  magical  power  in  dispelling  the 
eruption;  the  parts  affected  should  be  covered  with  gauze  wrung 
out  of  and  kept  constantly  wet  with  the  solution.  Apart  from  its 
well-known  local  anesthetic  action,  I  have  not  myself  observed  any 
marked  advantages  in  the  use  of  magnesium  sulphate.  Painting 
the  skin  with  collodion,  iodin,  or  strong  solutions  of  silver  nitrate 
(33  per  cent.),  about  an  inch  beyond  the  margin  of  the  erysipelatous 
patch,  has  in  some  cases  appeared  to  be  of  value  in  limiting  the  march 
of  the  infection;  but  when  it  is  remembered  that  the  dermatitis 
usually  subsides  of  itself  in  about  four  days,  it  is  seen  that  no  remedy 
can  be  said  to  be  specific.  When  the  subcutaneous  tissue  is  affected, 
the  treatment  is  the  same  as  for  cellulitis,  but  incisions  are  to  be 
employed  even  earlier,  owing  to  the  greater  intensity  of  the  inflam- 
mation. Anti-streptococcus  serum  is  harmless,  and  if  possible  should 
be  administered  in  all  severe  cases.  Erdman  gave  vaccines  an  extended 
trial  and  concluded  that  they  were  useless. 

GENERAL  AFFECTIONS  RESULTING  FROM  INFLAMMATION. 

In  addition  to  the  local  reaction  to  injury,  which  has  been  studied 
in  Chapter  I  under  the  heading  of  Inflammation,  there  is  also  a 
reaction  by  the  organism  as  a  whole.     In  even  the  simplest  cases 


US 


DISEASES  RESULTING  FROM  INFLAMMATION 


DAY  OF 
MONTH 

12 

i:; 

11 

16 

16 

(7 

IS 

111 

ioi 

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I  99 

< 

|  98 
97 
96 

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— 

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Fig.  27. — Temperature  chart 
of  aseptic  fever ;  contusion  of  hip ; 
aged  sixty-four  years.  Episcopal 
Hospital. 


the  local  reaction  is  accompanied  by  more  or  less  constitutional 
disturbance,  evidenced  chiefly  by  fever,  by  which  term  I  think,  with 
Adami,  it  is  convenient  to  designate  this  condition,  whether  or  not 
it  is  attended  by  elevation  of  temperature  (pyrexia).  Not  only  will 
many  aseptic  operations  be  followed  by  this  so-called  aseptic  fever 
(Genzmer  and  Volkmann,   1877),  but  some  patients  on  whom  no 

operation  has  been  done  (simple  fractures, 
etc.),  also  will  have  a  slight  rise  of  tem- 
perature and  other  signs  of  fever  on  the 
first  day  or  two  following  the  injury  (Fig. 
27).  In  most  cases  the  temperature  does 
not  exceed  100°  F.,  and  if  it  goes  beyond 
101°  F.  after  an  operation  it  is  very  prob- 
able that  infection  is  present.  Yet  in  one 
case  of  arthrodesis,  under  my  care  at  the 
Orthopaedic  Hospital,  the  temperature  rose 
to  over  102°  F.  on  the  second  day,  but 
the  wounds  pursued  a  perfectly  aseptic 
course.  The  cause  of  the  aseptic  fever 
was  formerly  ascribed  to  the  liberation  of 
fibrin  ferment  in  the  circulation,  due  to 
thrombotic  changes  and  phagocytic  action 
at  the  seat  of  injury;  but  more  modern  investigations  tend  to  show 
that  it  is  due  to  the  liberation  of  nucleins  and  albumoses.  It  is  not 
impossible  that  the  cocci  normally  found  in  the  deeper  layers  of 
the  skin  may  be  at  fault,  and  that  the  fever  is  really  not  aseptic 
in  the  strict  sense  of  the  word.  No  special  treatment  is  required; 
the  symptoms  subside  spontaneously  in  a  day  or  so.  A  laxative 
usually  is  beneficial. 

Sepsis.1 — When  bacteria  or  their  products  enter  the  circulation, 
there  is  developed  the  condition  known  as  sepsis.  If  the  products 
of  pathogenic  bacteria  enter  the  circulation,  but  the  bacteria  them- 
selves remain  in  the  tissues  at  the  seat  of  primary  infection,  the 
condition  is  named  toxemia;  this  is  to  be  distinguished  from  intoxi- 
cation, the  condition  due  to  poisoning  by  non-bacterial  products 
(drugs,  products  of  perverted  metabolism,  etc.).  Diphtheria  and 
tetanus  are  typical  examples  of  toxemia.  If  the  bacteria  themselves 
are  present  in  the  circulating  blood,  the  condition  is  termed  bac- 
teriemia;  typhoid  fever  is  a  typical  bacteriemia,  the  bacilli  circulating 
freely  in  the  blood,  and  producing  the  well-known  roseolar  eruption 
by  lodging  in  the  skin.  If  the  bacteria  which  circulate  in  the  blood 
are  highly  pathogenic,  as  the  streptococcus  or  staphylococcus,  the 
condition  is  properly  denominated  septicemia;  but  this  term  is 
frequently  used  negligently  to  describe  any  form  of  sepsis  whatever. 


1  The  terminology  employed  by  writers  in  describing  the  conditions  named 
below  is  by  no  means  uniform.  I  have  adopted  the  designations  which  have 
seemed  to  me,  after  considerable  study,  to  be  most  characteristic  of  the  maladies 
named,  and  least  confusing  to  the  student, 


SEPTICEMIA  69 

If  the  bacteria  circulating  in  the  blood  lodge  in  various  parts  of  the 
body,  forming  multiple  abscesses,  the  disease  is  named  pyemia. 
Finally,  if  the  constitutional  symptoms  are  due  to  absorption  of 
products  of  saprophytic  (non-pathogenic)  bacteria,  the  patient  is  said 
to  be  suffering  from  sapremia. 

Toxemia. — This  is  the  condition  formerly  described  as  inflammatory, 
traumatic,  surgical,  sympathetic,  or  symptomatic  fever.  As  modern 
methods  of  clinical  study  have  developed,  it  has  been  found  that 
this  condition  may  be  distinguished  from  aseptic  fever;  and  at  the 
present  day  it  is  usually  the  latter  that  is  meant,  when  reference  is 
made  to  inflammatory  or  surgical  fever.  For  the  development  of 
toxemia  it  is  necessary  for  bacteria  to  be  present,  and  they  are  rarely 
present  without  open  wound;  but  in  cases  of  intestinal  obstruction, 
and  in  infective  diseases  of  internal  organs  (appendicitis,  cholecys- 
titis, pyelitis)  it  is  the  rule  for  toxemia  to  exist.  If  no  focus  of 
infection  can  be  discovered,  the  sepsis  is  said  to  be  cryptogenetic. 
The  presence  in  the  blood  of  bacterial  toxins  causes  the  usual 
constitutional  symptoms  of  inflammation,  which  have  already  been 
detailed  (p.  31).  Traumatic  delirium  (p.  183)  is  probably  due  to 
toxemia.  If  the  aseptic  fever  customarily  seen  after  an  operation 
does  not  subside  in  two  or  three  days,  it  is  probable  that  some  septic 
focus  exists;  and  if  this  is  not  promptly  relieved  by  drainage,  the 
aseptic  fever  will  become  septic  in  nature,  and  the  patient  will  suffer 
from  toxemia,  the  commonest  form  of  sepsis. 

Treatment. — The  treatment  consists  in  removing  the  cause  of 
infection  when  this  is  possible,  and  in  thoroughly  draining  the  infected 
area  when  entire  removal  is  impossible  or  inexpedient.  Plenty  of 
water  should  be  introduced  into  the  patient's  system.  If  the  toxemia 
is  known  to  be  due  to  a  specific  cause  (tetanus  bacillus,  colon  bacillus) , 
antitoxic  serum  should  be  administered;  and  even  in  the  case  of  the 
common  infections  (streptococcus,  staphylococcus),  antitoxic  serum 
occasionally  is  of  benefit. 

Septicemia. — Septicemia,  which  is  the  commonest  form  of 
bacteriemia  seen  by  surgeons,  is  distinguished  at  its  onset  from 
toxemia  by  no  very  well  recognized  symptoms.  The  febrile  symptoms 
(pyrexia,  anorexia,  delirium,  etc.)  are  all  more  pronounced;  septic 
diarrhea  may  take  the  place  of  constipation,  and  intestinal  or  other 
internal  hemorrhages  may  occur  (Cf.  "critical  discharges,"  p.  32). 
Chilly  sensations  or  an  actual  chill  may  occur  early  in  the  disease, 
perhaps  due,  as  suggested  by  Adami  and  others,  to  relatively  high 
temperature  of  the  central  nervous  system.  The  temperature  usually 
is  not  very  high  (100°  to  102°  F.).  The  pulse  is  rapid  and  feeble, 
and  no  drugs  have  power  to  reduce  its  rate;  it  becomes  more  and 
more  rapid,  and  progressively  weaker  until  death,  which  is  the  usual 
termination  of  surgical  septicemia  (Fig.  28).  In  some  patients  who 
have  seemed  to  do  well  after  evacuation  of  septic  foci,  rapid  death 
occurs  from  so-called  terminal  infectwn  (Fig.  29).  Clinically  speak- 
ing,   it   is   usually   impossible   to   distinguish  between  toxemia  and 


70 


DISEASES  RESULTING  FROM   INFLAMMATION 


septicemia,  except  that  the  latter  is  little  influenced  by  treatment. 
Sometimes  by  blood  cultures  it  is  possible  to  ascertain  the  presence 
of  bacteria  in  the  circulating  blood  during  life;  but  as  the  number 
present  in  the  blood  may  be  few,  a  sterile  culture  is  usually  no  proof 
that  bacteriemia  does  not  exist.  The  presence  of  staphylococcus 
albus  in  the  culture  usually  is  due  to  contamination  from  the  skin. 
Treatment. — Treatment  of  septicemia,  as  already  indicated,  usually 
is  impotent  to  stay  the  course  of  the  disease.  As  pointed  out  by 
Lockwood  (1896),  at  autopsy  the  bacteria  are  found  even  in  the 
coronary  arteries  of  the  heart,  and  the  persistent  rapidity  of  the 
pulse  may  thus  be  accounted  for.  Nevertheless,  as  the  diagnosis 
is  sometimes  impossible,  except  at  autopsy,  all  the  measures  sug- 
gested for  the  treatment  of  toxemia  should  be  employed  in  these 
cases,  and  it  is  possible  that,  in  some  patients,  life  may  be  saved. 


DAY  OF 
MONTH 

!l 

10 

11 

12 

107 

106 

.105 

i  104 

H103 

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101 

100 

z 

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99 

98 

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Fig.  28.- — Puerperal  septicemia;  death. 
Episcopal  Hospital. 


Fig.  29.— Diffuse  purulent  peritonitis  from 
appendicitis.  Death  from  terminal  infec- 
tion (residual  abscess).     Episcopal  Hospital. 


Park  speaks  favorably  of  the  use  of  Unguentum  Crede,  which  is 
absorbed  through  the  skin;  and  he  thinks  benefit  is  derived  from 
"the  dissemination  throughout  the  system  of  the  antiseptic  virtues 
of  the  silver  itself."  He  also  commends  the  intravenous  use  of  a 
solution  of  Crede's  soluble  silver  (1  gram  of  silver  in  1000  c.c.  of 
water).  Barrows  has  used  formalin  solution  (1  to  5000)  intra- 
venously with  alleged  benefit. 

Pyemia. — Nearly  invariably  this  is  associated  with  thrombosis  and 
embolism  (p.  273).  The  staphylococcus  is  more  frequently  responsible 
than  the  streptococcus.  A  portion  {embolus)  of  the  septic  clot  or  a 
clump  of  bacteria  from  the  original  focus  of  infection  becomes  detached, 
and  is  transported  in  the  blood  stream  to  the  nearest  set  of  capil- 
laries, where  it  lodges  (embolism).  Once  lodged,  the  bacteria  present 
in   the   embolus  produce   suppuration  in   the   new   location,  and   a 


SYMPTOMS  OF  PYEMIA 


71 


secondary  or  metastatic  abscess  is  formed.  The  primary  thrombus 
usually  is  venous  in  location,  and  the  detached  clot  naturally  might 
be  expected  to  be  arrested  in  the  pulmonary  circulation;  but  for 
some  reason  this  is  not  always  the  case,  the  embolus  passing  safely 
through  the  lungs  and  being  arrested  first  by  some  portion  of  the 
systemic  capillary  network.  Occasionally,  when  the  embolus  first 
is  carried  into  the  venous  current  it  travels  against  the  usual  course 
of  the  blood,  and  lodges  in  some  portion  of  the  venous  channels 
distal  to  the  primary  lesion.  This  process  is  known  as  retrograde 
embolism;  it  may  occur  in  suppurations  in  the  neighborhood  of  the 
vena  cava,  or  in  the  face,  the  blood  current  in  the  angular  artery 
flowing  sometimes  toward  the  brain  and  sometimes  outward.  If 
the  primary  lesion  is  in  the  distribution  of  the  portal  vein  (e.  g.,  the 
appendix),  the  first  set  of  capillaries  encountered  by  the  embolus 


Fig.  30. — Temperature  chart  in  pyemia;  acute  osteomyelitis  of  calcaneum; 
abscess  of  brain;  death.     Episcopal  Hospital. 


will  be  the  hepatic,  and  multiple  liver  abscesses  will  result.  When 
in  the  systemic  circulation,  many  different  regions  and  organs  may 
become  affected;  metastatic  abscesses  in  the  subcutaneous  tissues 
or  joints  are  most  easily  detected;  but  those  in  the  kidneys,  spleen, 
liver,  lungs,  or  brain  sometimes  may  be  diagnosed  during  life. 
The  original  focus  may  be  any  suppurating  or  septic  lesion.  Burned 
surfaces  and  suppurative  lesions  of  bone  are  among  the  commonest 
causative  conditions.1 

Symptoms. — The  symptoms  are  those  of  septicemia,  with  certain 
important   modifications.     The   temperature   is   typically   irregular; 

1  The  localization  of  metastatic  infection  is  often  determined  by  the  existence 
of  a  place  of  lessened  resistance  in  the  patient's  body.  In  November,  1914,  I 
resected  and  plated  the  radius  and  ulna  for  malunion.  Healing  was  uneventful. 
In  June,  1916,  this  patient  developed  an  abscess  in  the  radial  scar,  following  an 
attack  of  acute  tonsillitis  and  cervical  adenitis. 


7i> 


DISEASES  RESULTING  FROM   INFLAMMATION 


its  variations  are  extreme,  and  the  absence  of  periodicity  is  charac- 
teristic (Fig.  30).  The  highest  temperature  (104°  to  106°  V.  or  higher) 
on  one  day  may  be  at  a  certain  hour  in  the  afternoon,  whereas  the 
next  day  the  temperature  may  reach  its  highest  point  in  the  morning 
or  not  until  late  at  night;  or  hyperpyrexia  may  be  absent  for  an 
entire  day  or  so.  Chills  are  frequent,  immediately  preceding  the  fall 
of  temperature,  and  are  often  indicative  of  the  lodgement  of  an 
embolus,  which  may  be  attended  by  sudden  pain. 

Prognosis.  The  prognosis  is  extremely  bad;  a  few  patients,  in 
whom  the  infection  seems  to  be  attenuated  and  the  course  of  the 
disease  chronic,  occasionally  recover. 


DAY  OP 

MONTH 

•i:> 

•_>»; 

21 

2S 

29 

11)1 

103 

cr 

I        0 

2 102 

a: 

HlOJ 
< 

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99 

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r 

S 

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$ 

RESP. 

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B 

35 

?i 

£ 

~, 

S 

Fig.  31. — Sapremia;  rapid  fall  of  temperature  after  evacuation  of  retained  secundines. 

Episcopal  Hospital. 

Treatment. — Treatment  is  the  same  as  for  septicemia.  Constant 
vigilance  is  needed  to  detect  and  locate  metastatic  abscesses,  and 
they  should  be  drained  immediately,  when  accessible;  and  unless 
the  patient  is  so  ill  that  a  formal  operation  will  hasten  his  death, 
the  surgeon  should  not  hesitate  to  evacuate  abscesses  of  the  internal 
organs  or  even  the  brain.  By  ligating  or  excising  the  main  venous 
trunks  leading  from  the  original  lesion,  the  infection  sometimes 
may  be  successfully  localized  (internal  jugular  in  mastoiditis,  ovarian 
in  parametritis,  angular  in  facial  phlegmon,  etc.). 

Sapremia. — When  dead  or  dying  tissue  is  in  contact  with  living 
cells,  the  ptomains  and  other  poisons  elaborated  by  the  saprophytic 
bacteria  which  infest  the  former  may  be  absorbed  into  the  patient's 
body,  and  thus  produce  the  usual  symptoms  of  toxemia.  When 
healing  in  the  wounded  area  has  progressed  to  the  stage  of  granu- 
lation, little  if  any  absorption  occurs;  but  injudicious  probing  of  a 
granulating  wound  may  destroy  this  barrier,  and  evidences  of  sepsis 
will  follow.  It  is  sometimes  impossible  to  distinguish  mild  grades 
of  sapremia  from  aseptic  fever,  or  from  a  slight  toxemia  due  to 
absorption  of  the  products  of  pathogenic  bacteria.     But  if  the  removal 


SAPREMIA 


73 


of  dead  and  decaying  tissue  restores  the  patient  abruptly  to  health,  the 
affection  presumably  was  sapremia.  Sapremia  is  seen  in  its  typical 
form  in  puerperal  cases,  absorption  occurring  from  the  retained  secun- 
dines  (Fig.  31).     Hectic  fever,  which  is  classed   by  Park  as  chronic 


Fig.  32. — Tuberculosis  of  hip;  hectic  temperature  arrested  by  excision  of  hip. 
Orthopaedic  Hospital. 

sapremia,  is  most  typical  in  patients  with  tuberculous  bone  disease, 
where  sinuses  exist,  and  as  a  consequence  the  decaying  bone  has 
become  infested  with  saprophytic  bacteria.  Fig.  32,  from  a  patient 
with  coxalgia,  formerly  under  my  care  at  the  Orthopsedic  Hospital, 
shows  hectic  fever  promptly  arrested  by  excision  of  the  hip. 


CHAPTER    III. 

SURGICAL  INFECTIONS. 

Situated  pathologically  half  way  between  pure  inflammation 
and  neoplasms,  exists  a  group  of  surgical  diseases  usually  described 
as  the  infections  granulomas.  This  term  implies  that  although  the 
lesions  are  definitely  known  to  be  caused  by  specific  microorganisms 
(which  is  not  the  case  with  tumors),  yet  the  tissue  reaction  to  these 
specific  irritants  is  characterized  rather  by  cell  accumulation  than  by 
actual  destruction  of  tissue  by  suppuration.  It  is  as  if  the  irritant 
were  too  timid  to  provoke  vigorous  resistance,  yet  too  enduring  to 
be  overcome  at  the  first  onslaught;  the  tissues  of  the  body  seem 
either  indifferent  to  the  invasion,  or  unable  to  continue  the  struggle 
with  the  success  which  usually  attends  their  warfare  in  acute  inflam- 
mation. While  the  more  important  of  these  modified  forms  of  inflam- 
mation (Tuberculosis,  Syphilis,  Actinomycosis)  partake  of  the  nature 
of  subacute  or  chronic  reactions,  there  are  others  (Anthrax,  Glanders, 
Gas  Gangrene,  Tetanus,  Hydrophobia)  in  which  the  reaction  is  acute, 
and  the  lesions  less  circumscribed,  but  which  it  is  nevertheless  con- 
venient to  discuss  in  the  same  chapter. 

CHRONIC  INFECTIOUS  SURGICAL  DISEASES. 

Tuberculosis. — Surgical  tuberculosis  includes  all  manifestations  of 
this  infection,  wherever  situated,  which  are  amenable  to  surgical 
treatment.  The  specific  cause  of  the  disease,  the  B.  tuberculosis 
(Koch,  1882),  gains  entrance  to  the  body  usually  through  the  digestive 
or  the  respiratory  tract.  It  has  been  held  by  good  authorities  that  the 
bacilli  may  pass  through  the  respiratory  or  intestinal  mucosa  and 
produce  no  lesions  in  it.  The  bacilli  lodge  most  frequently  in  the 
lung;  next  most  frequently  in  the  lymphatic  nodes — cervical,  bronchial, 
or  mesenteric.  Occasionally  infection  occurs  through  an  open  wound; 
inoculation  with  tuberculous  material  while  dissecting  produces  the 
so-called  anatomical  tubercle. 

The  bacillus  is  omnipresent  in  civilized  life,  and  it  is  by  no  means 
improbable  that  it  lives  as  a  parasite  in  the  bodies  of  most  apparently 
healthy  persons.  It  is  always  at  hand  to  attack  any  place  of  lessened 
resistance,  and  to  explain  its  prompt  appearance  in  such  locations 
it  is  usually  necessary  to  assume  that  it  was  present  previously,  though 
latent,  somewhere  in  the  patient's  body.  Scrofula,  formerly  con- 
sidered a  distinct  disease,  is  now  generally  recognized  as  identical 
with  tuberculosis;  it  may  be  considered  tuberculosis  in  its  primary, 
latent  state. 
(74) 


SURGICAL  TUBERCULOSIS  75 

Tuberculosis  is  most  often  primary  in  the  lungs,  digestive  tract, 
lymph  nodes,  urinary  and  sexual  organs,  and  the  bones.  Surgical 
tuberculosis,  which  is  said  usually  to  be  secondary  to  an  inconspicuous 
lesion  of  the  lungs,  is  seen  especially  in  the  lymph  nodes,  the  bones 
and  joints,  the  sexual  organs,  peritoneum,  etc.1 

Pathology. — The  local  lesion  produced  by  the  B.  tuberculosis  is 
called  a  tubercle;  its  proper  adjective  is  tuberculous;  and  it  should  be 
distinguished  from  a  tubercule,  a  term  which  describes  the  anatomical 
form  of  the  lesion  of  a  skin  eruption  which  is  called  tubercular,  but 
which  is  in  no  way  connected  with  tuberculosis.  When  the  B.  tuber- 
culosis begins  to  proliferate  in  the  tissues,  its  first  effect  is  to  exert 
chemotactic  action  upon  the  connective  tissue  and  endothelial  cells 
in  its  immediate  vicinity.  It  does  not  exert  positive  chemotaxis  upon 
the  leukocytes  circulating  in  the  blood,  and  leukopenia  not  leukocy- 
tosis is  the  rule;  but  the  number  of  circulating  lymphocytes  may  be 
relatively  increased.  Locally,  as  the  tissue  cells  accumulate,  their 
appearance  changes,  the  cells  swell  up,  become  pale,  and  resemble 
epithelial  cells  so  closely  that  they  are  widely  known  as  epithelioid 
cells.  This  accumulation  of  epithelioid  cells  around  the  tubercle 
bacilli  causes  an  anemia  of  the  central  area,  and  the  epithelioid  cells 
themselves  gradually  suffer  from  lack  of  nourishment,  and,  instead 
of  actively  dividing  and  multiplying  their  number  as  at  first,  they 
seem  to  be  unable  longer  to  carry  on  the  processes  of  independent 
existence,  and  their  cell  bodies  fuse;  so  that  among  the  epithelioid  cells 
there  soon  appear  two,  three,  or  more  large  cells  with  multiple  nuclei, 
arranged  around  the  periphery  or  at  the  two  poles  of  the  cell — the 
so-called  giant  cells.  In  the  area  immediately  surrounding  the  giant 
cells  and  epithelioid  cells,  the  lymphocytes  accumulate;  while  the 
center  of  the  tubercle  is  composed  of  tissue  and  cellular  debris  under- 
going caseous  degeneration,  which  is  the  form  of  anemic  necrosis 
particularly  characteristic  of  tuberculosis.  Some  phagocytosis  exists, 
but  it  sometimes  seems  as  if  the  tubercle  bacilli  continued  their  exist- 
ence as  parasites  even  within  the  cell  bodies  of  their  victim:  they  are 
most  apt  to  be  seen  within  the  giant  cells;  they  are  frequently  present 
in  the  epithelioid  cells;  but  are  said  never  to  be  found  within  the 
lymphocytes.  The  histological  tubercle,  thus,  may  be  represented 
diagrammatically  (Fig.  33)  as  composed  of  three  portions:  (1)  a  cen- 
tral caseous  or  necrotic  area,  in  wdiich  may  be  a  giant  cell,  its  own 
center  showing  commencing  caseation;  (2)  the  epithelioid  cells  sur- 
rounding the  caseous  center,  and  (3)  the  peripheral  aggregation  of 
lymphocytes. 

The  products  of  the  tubercle  bacillus,  spoken  of  generically  as 
tuberculin,  are  not  very  well  understood;  it  seems  probable,  never- 
theless, that  caseation  is  induced  by  the  toxins  set  free  from  the 
bodies  of  the  bacilli  when  they  die,  but  that  the  irritant  action  of  the 

1  Some  modern  investigators  believe  that  the  bovine  form  of  Tubercle  bacillus 
is  responsible  for  "surgical  tuberculosis,"  while  the  human  form  is  that  usually 
found  in  the  lungs. 


76 


si  lialc  \l,    INFECTIONS 


living-  bacilli  is  only  sufficient  to  provoke  cell  accumulation  and  multi- 
plication. These  various  products  of  tubercle  bacilli  usually  exist 
in  greater  or  less  amount  in  the  body  fluids  and  excretions  of  animals 
suffering  with  tuberculosis;  and,  when  injected  into  other  animals 
afflicted  with  tuberculosis,  the  tuberculin  contained  in  them  produces 
a  characteristic  reaction  which  may  be  used  for  the  purpose  of  diag- 
nosis (p.  79). 


Fig.  33. — Section  through  a  tubercle.     Upon  the  margin  of  the  tubercle  lymphoid  cells 
may  be  seen;  in  the  center  epithelioid  cells  and  a  giant  cell.     (Lexer-Bevan.) 


The  primary  tubercle  may  be  replaced  by  granulation  tissue  former! 
from  the  surrounding  connective  tissue  cells,  and  healing  may  occur 
in  a  manner  similar  to  that  of  simple  inflammation.  Or  the  "pyogenic 
membrane"  may  isolate  and  encapsulate  the  tubercle,  and  thus  the 
disease  may  be  arrested;  calcification  is  a  frequent  sequel.  On  the 
other  hand,  some  of  the  bacilli  may  escape  through  the  cordon  of 
epithelioid  cells  on  guard,  and,  settling  in  a  neighboring  portion  of 
the  tissues,  they  may  there  proceed  to  form  a  new  tubercle;  and  as 
many  more  tubercles  are  formed,  the  area  may  become  visible  to  the 
naked  eye,  and  the  center  of  the  entire  mass  may  be  seen  as  a  caseous 
nodule  surrounded  by  comparatively  healthy  tissue  (Fig.  34).  Two 
processes  may  thus  be  initiated — either  productive  or  degenerative; 
the  former  gives  rise  to  tuberculous  {fungous)  granulation  tissue,  fre- 
quently described  as  the  tuberculous  gumma  (Figs.  35  and  37),  because 
it  is  very  difficult  to  distinguish  it  histologically  from  the  gummas  of 


SURGICAL  TUBERCULOSIS 


77 


syphilis,  actinomycosis,  etc.;  whereas  the  degenerative  changes  result 
in  the  formation  of  a  cold  abscess,  so  named  to  distinguish  it  from  the 
ordinary  abscess  of  inflammation,  which  is  characterized  by  its  heat. 


8 


M  J 


Fig.  34. — Cross-section  of  tuberculous  testicle,  showing  areas  of  caseation.  Skin 
adherent.  One  sinus  has  been  divided  in  the  section.  From  a  patient  in  the  Episcopal 
Hospital. 

Tuberculous  granulation  tissue  has  a  great  tendency  to  displace  all 
normal  tissues  with  which  it  comes  in  contact:  in  bones  it  causes  the 
disappearance  of  the  normal  osseous  structure;  in  joints  it  grows  upon 


Fig.  35. — Tuberculous  gummas  of  leg,  in  a  baby,  aged  eight  months. 
Children's  Hospital. 

the  synovial  membranes,  producing  fibrous  ankylosis;  in  tendon 
sheaths  it  spreads  along  their  course,  gradually  invading  the  tendons 
and  in  time  causing  their  .entire  disappearance.     The  degenerative 


SURGICAL  INFECTIONS 


changes,  which  by  the  process  of  coagulation  and  liquefaction  necrosis 
chance  tuberculous  granulation  tissue  into  cold  abscesses,  are  probably 
due,  as  already  pointed  out,  to  excessive  destruction  of  tubercle 
bacilli  with  liberation  of  their  endotoxins,  and  to  the  action  of  fer- 
ments set  free  by  the  death  of  cellular  protoplasm.  When  the  cheesy 
pus  finds  an  exit  for  itself,  the  tuberculous  abscess  is  converted  into 
a  tuberculous  sinus,  or  if  the  walls  of  the  abscess  cavity  are  unable 
to  collapse,  as  in  bone,  and  often  in  the  lungs,  a  tuberculous  cavity 
remains.  As  the  tuberculous  sinus  heals,  it  becomes  converted  into  a 
tuberculous  ulcer  (Fig.  36).  It  was  once  hoped  that  by  the  admin- 
istration of  tuberculin  to  tuberculous  patients  their  tuberculous  lesions 
could  be  disintegrated  and  caused  to  discharge;  but,  unfortunately, 
it  has  been  found  that  sudden  disintegration  of  tuberculous  foci  is 


Fig.  36. — Scrofulous  ulcers,  duration  one 
month.  Two  months  after  incomplete 
operation  for  recurrent  tuberculous  cervical 
adenitis.     Episcopal  Hospital. 


Fig.  37.— Tuberculous  dactylitis  (tuber- 
culous gummas  of  fingers).  Children's 
Hospital. 


more  apt  to  be  followed  by  acute  generalized  miliary  tuberculosis, 
which  may  be  succinctly  described  as  tuberculous  pyemia.  Any 
secondary  infection,  moreover,  of  a  tuberculous  focus,  is  prone  to 
aggravate  the  condition  by  weakening  the  protective  layer  of  epithe- 
lioid and  lymphoid  cells  which  surround  the  tuberculous  area.  The 
great  danger  when  any  cold  abscess  discharges  is  that  of  secondary 
(pyogenic)  infection.  As  Calot  says,  the  opening  of  a  cold  abscess 
is  the  opening  of  a  door  by  which  death  soon  enters. 

Diagnosis. — The  detection  of  the  tubercle  bacillus  in  the  lesions 
renders  the  diagnosis  certain;  but  in  the  vast  majority  of  cases  this 
is  not  requisite,  as  the  clinical  appearances  are  quite  sufficient  to 
justify  the  diagnosis  of  tuberculosis.  The  indolence  of  the  reaction, 
the  slow  course  of  the  disease;  the  characteristic  cheesy  material 
discharged  from  the  sinuses;  the  absence  of  leukocytosis  in  uncom- 


SURGICAL   TUBERCULOSIS  79 

plicated  cases;  and  the  general  appearance  of  the  patient;  these  all, 
when  combined  in  one  individual,  make  the  actual  detection  of  the 
tubercle  bacillus  an  unnecessary  task  in  most  cases  of  external  tuber- 
culosis (bones,  joints,  lymph  nodes,  skin,  etc.).  In  tuberculosis  of 
certain  internal  organs,  especially  the  kidney,  it  is  highly  desirable 
to  detect  the  bacilli  in  the  excretions.  Another  aid  to  diagnosis  is 
the  tuberculin  test  (p.  76):  old  tuberculin1  is  that  generally  used, 
the  initial  dose  in  adults  being  one-tenth  of  a  milligramme  (0.0001 
gramme)  hypodermically ;  this  may  be  increased  at  subsequent  injec- 
tions to  1  and  even  to  5  milligrammes.  The  hypodermic  use  of  tuber- 
culin gives  reasonably  accurate  results,  and  I  prefer  this  method  to  the 
conjunctival  test  of  Calmette,  or  to  the  inunction  of  Moro's  tuberculin 
ointment.  The  cutaneous  reaction  of  v.  Pirquet  is  usually  to  be 
preferred  in  children  (under  twelve  years  of  age),  but  as  it  appears 
to  indicate  the  existence  of  latent  or  healed  tuberculosis  (very  rare 
in  children)  quite  as  readily  as  an  active  focus,  it  is  not  regarded  as 
so  accurate  as  the  hypodermic  test  for  adults.  The  hypodermic  test, 
unless  repeated,  causes  reaction  only  when  there  is  an  active  focus  in 
the  body;  but  it  does  not  necessarily  indicate  that  the  lesion  suspected 
is  tuberculous.  If,  however,  its  use  causes  an  exacerbation  of  symp- 
toms in  the  suspected  lesion  (focal  reaction)  there  can  be  very  little 
doubt  of  its  tuberculous  character.  After  the  hypodermic  injection 
has  been  given,  the  patient's  temperature  should  be  recorded  every 
two  hours  for  a  period  of  24  hours:  a  positive  reaction,  indicating  the 
presence  of  tuberculosis,  consists  in  an  abrupt  rise  of  temperature  to 
101°  or  102°  F.,  occurring  usually  about  the  twenty-second  hour.2 
Sometimes  a  chilly  sensation  is  experienced  as  the  temperature 
begins  to  rise.  If  the  first  injection  is  negative,  a  second  and  even 
a  third  may  be  given,  gradually  increasing  the  dose.  I  have 
never  seen  any  untoward  result.  The  reaction  is  positive  in  most 
cases  of  tuberculosis  not  in  advanced  stages;  it  is  usually  negative 
when  secondary  infection  is  present,  with  amyloid  changes  in  the 
viscera  and  a  hectic  temperature;  but  in  such  cases  the  diagnosis  is 
easy  enough  without  this  test.  Indeed  it  is  quite  useless  to  employ 
a  tuberculin  test  if  the  diagnosis  can  be  made  clinically.  In  v.  Pir- 
quet's  method  three  small  areas  on  the  arm  are  abraded,  and  into 
one  or  two  of  these  the  tuberculin  is  rubbed;  the  other  abrasions 
being  used  as  controls.  On  the  second  or  third  day,  in  tubercu- 
lous cases,  the  infected  area  shows  a  characteristic,  erythematous, 
papular,  and  even  vesicular  eruption. 

1  Old  tuberculin  is  a  filtrate  of  a  concentrated  glycerin  extract  of  tubercle  bacilli ; 
it  is  possible  that  some  of  the  bacilli  may  not  be  excluded  by  the  filter;  to  obviate 
this  danger  Koch  prepared  two  new  tuberculins:  of  these  Tuberculin  Oberst 
(T.  O.)  is  the  supernatant  liquid  obtained  by  centrifugalization  of  a  concentrated 
glycerin  extract- of  tubercle  bacilli;  the  sediment  which  forms,  containing  the  bacilli 
themselves,  is  ground  up  and  again  centrifugalized,  and  forms  Tuberculin  Rest 
(T.  R.).  T.  O.  resembles  old  tuberculin,  and  may  be  used  instead  of  it  in  diagnosis; 
T.  R.  is  used  in  treatment. 

2  An  earlier  rise,  especially  within  a  few  hours  of  the  injection,  probably  is 
due  to  some  contamination. 


80  SURGICAL  INFECTIONS 

Treatment. -Constitutional  and  hygienic  treatment  are  quite  as 
important  in  surgical  as  in  medical  tuberculosis.  The  majority  of 
patients  with  surgical  tuberculosis  are  children  of  a  school-going 
age.  It  is  better  for  them  to  give  up  school  for  one  or  two  years, 
until  their  constitution  is  strong  enough  for  them  to  conquer  the  dis- 
ease, than  to  attempt  to  keep  up  in  their  classes  and  grow  physically 
worse  and  worse.  It  may  not  be  possible  for  them  to  sleep  in  the 
open  air,  but  they  can  at  least  sleep  with  all  the  windows  in  their 
room  open,  and  be  out  of  doors  as  much  as  possible  during  the  day. 
In  hospitals  provided  with  suitable  roof-gardens,  where  the  patients 
may  be  kept  in  the  open  air  practically  twenty-four  hours  out  of  the 
twenty-four,  it  has  been  found  that  operative  treatment  is  scarcely 
ever-required.  In  institutions  where  it  is  impossible  for  one  reason 
or  another  to  keep  the  bed-ridden  patients  out  of  doors  constantly, 
it  usually  is  quite  possible  for  their  beds  to  be  wheeled  out  of  doors 
and  left  out  from  7  a.m  to  7  p.m.  It  is  by  no  means  necessary  to  have 
a  hospital  in  the  country  for  these  patients:  porches  and  balconies, 
even  if  roof-gardens  cannot  be  obtained,  will  accomplish  the  same 
results  in  the  most  thickly  settled  parts  of  the  city.  Hand  in  hand 
with  the  open  air  treatment  must  go  full,  wholesome  diet,  especially 
milk  and  eggs;  and  the  only  medicine  usually  required  is  cod  liver 
oil,  which  seems  to  act  better  than  any  other  remedy  in  increasing 
the  appetite  and  causing  the  patients  to  put  on  flesh.  In  the  rare 
cases  where  it  does  not  do  good,  the  syrup  of  the  iodide  of  iron,  the 
compound  syrup  of  the  hypophosphites,  or  other  remedies,  may  be 
tried. 

Locally,  I  am  convinced  that  tuberculosis  of  the  soft  parts  demands 
a  different  treatment  from  that  of  bone.  In  the  latter  case  such  re- 
markable results  are  obtained  in  children  by  local  rest,  without  opera- 
tive interference,  that  I  am  extremely  conservative  in  urging  any 
other  surgical  treatment:  the  use  of  plaster  casts,  braces,  weight 
extension  in  bed,  together  with  proper  hygienic  treatment,  will  cure 
nearly  all  patients  in  whom  these  methods  are  adopted  early.  As 
regards  tuberculosis  of  the  soft  parts  (lymph  nodes,  generative  and 
urinary  organs,  peritoneum),  however,  local  rest  is  usually  impossible 
to  secure,  and  I  feel  sure  that  better  results  are  obtained  by  radical 
operation,  removing  the  entire  disease;  and  when  this  is  impossible, 
as  in  the  abdomen,  at  least  removing  the  primary  focus.  The  local 
treatment  adapted  to  each  form  of  tuberculosis  will  be  pointed  out 
when  the  surgery  of  those  portions  of  the  body  is  discussed. 

Syphilis. — This  is  an  infectious  granuloma  due  to  inoculation  with 
the  Treponema  pallidum  (Spirochceta  pallida),  a  parasite  described  by 
Schaudinn  and  Hoffman  (1905),  and  obtained  in  pure  culture  in  1911 
by  Noguchi  and  by  Hoffmann. 

Pathology. — This  organism  usually  gains  access  to  the  tissues 
through  some  abrasion  or  excoriation  of  the  skin  or  mucous  mem- 
branes, being  inoculated  directly  from  a  sore  in  another  person  suffer- 
ing from  syphilis  (immediate  contagion).     Occasionally  mediate  con- 


PATHOLOGY  OF  SYPHILIS 


81 


tag  ion  occurs,  the  virus  being  transmitted  by  means  of  soiled  towels, 
eating  and  drinking  utensils,  etc.  When  inoculated,  there  follows  a 
period  of  incubation,  averaging  from  three  to  five  weeks,  during  which 
the  microbes  multiply  at  the  site  of  primary  invasion,  and  are  carried 
by  the  lymph  channels  to  the  nearest  lymph  nodes;  so  that  by  the 
time  the  local  reaction  appears  at  the  site  of  original  inoculation,  the 
disease  is  already  diffused  in  the  patient's  body.  Neisser  found  the 
blood  contained  the  virus  as 
early  as  the  fifth  day  after 
inoculation.  The  local  reac- 
tion (chancre)  resembles  the 
tubercle  in  some  ways :  a  col- 
lection of  round  cells  occurs, 
and  there  may  be  a  few  giant 
cells  present ;  but  the  chancre 
is  particularly  characterized 
by  the  great  proliferation  of 
the  endothelial  cells  lining  the 
capillaries.  By  proper  stain- 
ing methods  the  presence  of 
the  Treponema  pallidum  may 
be  demonstrated;  otherwise 
the  histological  picture  is  not 
regarded  as  conclusive,  though 
endothelial  proliferation  is 
always  suggestive  of  a  syphi- 
litic lesion. 

The  chancre  is  situated  in  the  true  skin  (derma) ;  usually  when  first 
seen,  exfoliation  of  the  overlying  epidermis  has  occurred,  converting 
the  primary  lesion  into  a  superficial  erosion;  in  some  cases  the  local 
reaction  is  much  more  marked,  and  the  deep  or  Hunterian  chancre 
develops.  Usually  very  soon  after  the  appearance  of  the  chancre, 
enlargement  of  the  regional  lymph  nodes  may  be  detected;  and  not 
infrequently  the  lymphatics  leading  to  these  nodes  are  palpably 
enlarged.  There  follows  the  second  period  of  incubation,  lasting  on  an 
average  about  six  weeks;  during  this  period  the  virus  of  the  disease 
is  spreading  past  the  first  group  of  lymph  nodes,  and  is  carried  by 
the  blood-stream  all  over  the  patient's  body.  Various  prodromal 
symptoms,  such  as  fever,  malaise,  headache,  vague  "rheumatic" 
pains,  etc.,  may  be  experienced  during  this  time.  As  in  typhoid  fever, 
the  infecting  organisms  lodge  first  in  the  cutaneous  capillaries,  and 
the  well  known  rashes  of  syphilis  {secondary  lesions,  syphilodermas) 
are  produced;  at  the  same  time  the  lymph  nodes  all  over  the  body 
become  enlarged,  especially  the  posterior  cervical  and  epitrochlear 
groups.  The  lesions  of  this  secondary  period  are  not  confined  entirely 
to  the  skin;  the  mucous  membranes  usually  are  also  affected,  the 
eruption  appearing  in  modified  form  in  the  mouth,  the  fauces,  and  the 
vagina.  The  histological  picture  of  these  secondary  lesions  presents 
6 


Fig.  38. — Treponema  pallidum  (Spirochseta 
pallida):  a,  red;  b,  white-blood  corpuscles. 
(Lexer-Bevan.) 


82  SURGICAL  INFECTIONS 

nothing  pathognomonic  of  syphilis;  but  the  proliferation  of  the  endo- 
thelial cells  lining  the  bloodvessels  is  usually  sufficient  at  least  to  sug- 
gest the  syphilitic  nature  of  the  disease,  and  the  specific  organism 
usually  may  be  delected  by  smears  made  from  the  ulcerated  sores. 
Still  later,  more  or  less  typical  lesions  appear  in  the  deeper  structures 
and  in  the  internal  organs.  These,  which  are  known  as  gummas,  are 
characteristic  of  the  third  stage  of  syphilis;  they  consist  essentially 
of  an  aggregation  of  round  lymphoid  cells,  with  an  occasional  giant 
cell  at  the  periphery  of  the  lesion;  bloodvessels  are  less  conspicuous 
in  the  tertiary  than  in  the  secondary  lesions  of  syphilis.  The  Tre- 
ponema pallidum  rarely  can  be  found  in  these  tertiary  lesions;  it  is 
practically  never  to  be  detected  in  those  with  pyogenic  infections. 
As  in  the  case  of  tuberculosis,  so  here,  there  is  a  marked  tendency  for 
the  center  of  these  lesions  to  undergo  various  forms  of  degeneration, 
of  which  the  hyaline  and  fatty  are  the  most  usual.  Instead  of  the 
cheesy  pus  so  characteristic  of  tuberculous  suppuration,  the  product 
of  syphilitic  suppuration  is  known  as  gummatous  pus.  In  tertiary 
as  well  as  in  secondary  lesions,  there  is  a  marked  tendency  for  the 
disease  to  be  productive  at  the  periphery  of  the  lesions,  while  degenera- 
tion occurs  in  the  center.  This  is  thought  to  account  for  the  charac- 
teristic serpiginous  form  of  some  of  the  later  skin  lesions  (Fig.  1020). 
The  tertiary  lesions  of  syphilis  heal  by  granulation  and  cicatrization, 
with  resulting  deformity  from  contraction  of  the  scar-tissue.  The 
•scars  are  typical,  both  on  surfaces  and  in  the  interior  of  organs — in 
the  former  situations  the  regular  outline,  circular  form,  and  depressed, 
shiny  base  of  the  cicatrix  are  nearly  pathognomonic  of  a  former 
syphilitic  lesion;  while  the  radiating,  star-like  cicatrices  in  the  internal 
organs  usually  may  be  recognized  at  a  glance.  Secondary  infection 
with  pyogenic  bacteria  is  a  frequent  occurrence  in  gummas;  this 
hastens  the  destructive  process  and  increases  the  subsequent  deformity. 

No  tissues  are  exempt  from  the  ravages  of  syphilis.  The  favorite 
seats  for  the  secondary  lesions  are  the  skin,  mucous  membranes,  and 
iris.  In  tertiary  syphilis  the  periosteum,  bones,  and  joints;  deep  sub- 
cutaneous tissues;  palate  and  nasal  structures,  iris,  retina,  and  choroid; 
the  internal  and  generative  organs ;  and  the  nervous  system ;  are  those 
most  usually  affected. 

This  brief  sketch  of  the  pathology  of  syphilis  will  suffice  for  the 
present  chapter.  The  clinical  aspects  of  the  disease,  as  well  as  the 
treatment,  will  be  discussed  in  Chapter  XXVI,  while  important 
syphilitic  lesions  of  the  various  parts  and  systems  of  the  body  will 
be  described  in  chapters  devoted  to  regional  and  systemic  surgery. 

Actinomycosis. — The  cause  of  this  disease  commonly  is  known  as 
the  Ray  Fungus,  from  its  appearance  under  low  powers  of  the  micro- 
scope (Fig.  39);  but  scientists  differ  as  to  wThether  it  shall  be  classed 
with  the  moulds  (hyphomycetes)  or  with  bacteria  (schizomycetes). 
This  organism  is  found  growing  on  hay  and  straw,  and  also  in  the 
ground,  whence  it  may  be  incorporated  in  growing  vegetable  matter. 
It  was  first  observed  by  von  Langenbeck  in  1845,  in  the  pus  from  a 


ACTINOMYCOSIS 


SI! 


Fig.    39. — Grains  of  actinomyces  from 
human  pus.      X  450.     (Marwedel.) 


patient  with  caries  of  the  vertebrae.     Formerly,  instances  of  the  dis- 
ease were  considered  sarcomatous  or  carcinomatous  in  nature.     In 
cattle  the  ray  fungus  is  a  frequent  source  of  disease  (lumpy  jaw, 
swelled  head) ;  but  few  cases  have  been  observed  in  which  actual  trans- 
mission from  animal  to  man  has  occurred.    The  usual  source  of  infec- 
tion in  man  is  believed  to  be  chew- 
ing of   diseased    grain;  but   J.  H. 
Wright  (1905)  claims  that  the  ray 
fungus    is  quite   commonly   found 
in   healthy  mouths,   both  of  man 
and   beast,    and   asserts    that   the 
action  of  the  cereal  is   merely  to 
prepare  a  locus  minoris  resistentioe 
where  the  fungus  can  develop. 

Pathology. — Like  the  other  in- 
fectious granulomas,  actinomycosis 
is  characterized  by  a  local  produc- 
tive reaction.  There  is  very  little 
tendency  to  necrosis;  but  in  man- 
kind secondary  infections   are  the 

rule,  and  hence  suppuration  is  much  more  frequent  than  in  the  lower 
animals.  The  cellular  infiltrate  surrounding  the  focus  of  disease 
consists  of  small  round  cells,  giant  and  epithelioid  cells;  conversion 
into  granulation  tissue  occurs,  and  this  tends  to  cicatrize.  The  dis- 
ease is  prone  to  extend  along  sinuous  and  branching  tracts,  suppura- 
tion occurring  in  the  center,  while  the  sinuses  are  lined  with  the 
granulomatous  tissue.  In  the  pus  discharged  from  these  tracts, 
the  colonies  of  the  fungus  are  visible  to  the  naked  eye,  as  minute 
yellow  granules;  these  impart  to  the  fingers  a  gritty  sensation  due  to 
the  presence  of  calcareous  salts.  The  disease  is  chronic,  and  unless 
vital  parts  are  attacked,  life  may  be  prolonged  for  years.  Occasion- 
ally metastatic  foci  are  developed  through  the  blood-stream;  but 
the  disease  never  extends  by  the  lymphatics,  and  enlargement  of  the 
regional  lymph  nodes  usually  is  an  indication  of  secondary  infection 
(Frazier,  1906).' 

Symptoms. — Four  distinct  varieties  of  human  actinomycosis  are 
recognized:  the  oral,  the  pulmonary,  the  abdominal,  and  the  cutaneous. 
The  origin  of  the  first  has  already  been  described;  from  the  tissues  of 
the  mouth  proper,  the  jaws,  the  cheeks,  the  neck,  and  even  the  skull 
and  brain  may  be  invaded.  The  pulmonary  form,  due  to  inhalation, 
usually  assumes  the  character  of  a  low  grade  basal  pneumonia;  pleural 
effusion  and  invasion  of  the  thoracic  parietes  are  frequent.  The 
spine  may  be  involved,  and  the  cold  abscesses  formed  may  closely 
simulate  those  of  tuberculosis.  Abdominal  actinomycosis,  especially 
frequent  in  the  neighborhood  of  the  cecum,  is  of  the  hyperplastic 
type,  abscess  formation  and  intestinal  perforation  being  rare;  the  dis- 
ease tends  rather  to  produce  adhesions  to  the  parietal  peritoneum, 
and  to  invade  the  abdominal  wall,  producing  there  the  characteristic 


si 


SURGICAL  INFECT l()SS 


lesions  seen  whenever  the  skin  is  invaded.  Cutaneous  actinomycosis 
frequently  may  be  diagnosed  without  microscopical  examination  of 
the  pus;  the  sinuses,  with  the  involuted,  hypertrophied  skin;  the 
chronic  and  nearly  painless  course  of  the  disease;  the  typical  "board- 
like" induration,  sharply  outlined;  and  perhaps  the  presence  of  hard 
cords  under  the  skin  running  from  the  main  lesions  out  in  various 
directions;  all  make  a  picture  which  is  not  readily  mistaken  for 
anything  else. 

Diagnosis.  This  must  be  made  from  malignant  tumors,  which  may 
be  closely  simulated  by  the  hyperplastic  form;  from  osteomyelitis  and 

tuberculous  lesions  of  bones  and  joints;  from 
inflamed  sebaceous  cysts  of  the  face  (Fig. 
40),  which,  as  pointed  out  by  Lexer,  some- 
times bear  a  striking  resemblance  to  actino- 
mycosis; and  from  gummatous  and  other 
syphilitic  lesions. 

Treatment. — If  complete  extirpation  is 
possible,  this  should  be  done;  but  in  most 
cases  the  surgeon  must  content  himself  with 
freely  opening  all  the  sinuses,  removing  the 
granulation  tissue  with  Volkmann's  sharp 
spoon  (Fig.  509),  cauterizing  the  remaining 
tracts  with  the  actual  cautery  or  some  chem- 
ical caustic  (chloride  of  zinc  10  per  cent.), 
and  packing  the  wounds  with  iodoform 
gauze.  Iodide  of  potassium  is  said  to  have 
a  remarkable  effect,  administered  in  large 
doses  for  two  or  three  weeks  at  a  time  and 
then  discontinued  for  one  week.  Bevan 
(1908)  has  used  cupric  sulphate  pills,  one 
quarter  of  a  grain,  thrice  daily,  with  marked 
benefit;  he  also  irrigates  the  wound  with  1  per  cent,  cupric  sulphate 
solution.  This  method  is  based  on  the  agricultural  treatment  of  the 
diseased  grain.  Out  of  door  life,  and  hygienic  measures,  as  for  tuber- 
culosis, are  of  almost  equal  importance  with  topical  remedies. 

Madura  Foot. — Madura  foot,  first  observed  in  Madura,  India,  in 
1712,  is  occasionally  seen  in  America.  It  is  due  to  a  fungus  closely 
resembling  the  actinomyces;  one  foot  only  is  involved  as  a  rule; 
very  occasionally  the  hand  is  affected.  A  painless  swelling  forms  on 
the  sole;  softening  and  suppuration  follow.  The  course  is  chronic. 
Fistulas  form,  heal,  and  again  break  open.  Finally  all  the  structures 
of  the  foot  are  invaded.    Amputation  is  the  best  treatment. 

Blastomycosis. — This  is  a  surgical  infection  whose  chief  lesions 
are  manifested  in  the  skin,  caused  by  organisms  of  undetermined 
biological  position,  known  as  blastomycetes.  A  few  cases  of  systemic 
infection  have  also  been  reported.  According  to  Bevan  (1908)  "the 
cutaneous  lesions  have  been  mistaken  most  often  for  verrucous  tuber- 
culosis, less  often  for  syphilis,  and  occasionally  for  epithelioma.     .     .     . 


Fig.  40. — Multiple  seba- 
ceous cysts  of  the  face  simu- 
lating actinomycosis.  Epis- 
copal Hospital. 


ANTHRAX  85 

Tuberculosis  is  the  disease  which  is  most  apt  to  be  confused  with 
systemic  blastomycosis."  The  diagnosis  is  best  made  by  micro- 
scopical examination  of  the  pus  from  the  cutaneous  lesions,  or  by 
excluding  the  existence  of  tuberculosis  by  the  usual  tests.  Bevan 
thinks  potassium  iodide  is  the  most  valuable  remedial  measure;  he 
gives  as  much  as  600  grains  a  day,  well  diluted.  Cupric  sulphate  has 
also  been  used.  Hygienic  measures  are  important.  In  advanced 
cases  the  lesions  must  be  treated  surgically,  by  excision,  curettement, 
cauterization,  etc. 

Rhinoscleroma. — Hhinoscleroma,  a  chronic  infiltrating,  productive 
infection  of  the  nasal  mucous  membrane  (rarely  of  the  pharynx, 
larynx,  and  hard  palate),  is  almost  unknown  in  this  country,  though 
common  in  Austria  and  southwestern  Russia.  It  is  possibly  due  to  a 
diplobacillus  (v.  Frisch,  1882).  It  is  highly  destructive,  invading  all 
surrounding  tissues,  and  clinically  resembling  other  infectious  granu- 
lomas. Excision  is  the  best  treatment;  when  this  is  impossible 
enough  of  the  growth  should  be  removed  to  facilitate  breathing. 

ACUTE  INFECTIOUS  SURGICAL  DISEASES. 

Anthrax. — This  disease,  due  to  infection  by  the  B.  anthracis 
(Davaine,  1873;  Koch,  1877),  is  common  in  sheep,  horses,  etc.,  and 
may  be  transmitted  to  man  directly,  or  through  contagion  from  wool, 
hides,  etc.  Invasion  occurs  through  abrasions  of  the  skin  or  mucous 
membrane;  or  through  the  respiratory  or  the  intestinal  tract.  The 
period  of  incubation  is  one  or  two  days.  The  local  reaction  consists 
in  a  cellular  and  serous  exudate,  producing  marked  edema,  with  a 
tendency  to  central  necrosis.  Eighty-five  per  cent,  of  cases  affect 
the  head,  face,  and  neck.  In  severe  cases  anthrax  bacilli  enter  the 
blood  current,  and  bacteriemia  results;  as  the  bacilli  are  too  large  to 
pass  through  capillaries  of  ordinary  size,  they  are  arrested  at  various 
places  and  produce  carbunculoid  lesions  in  these  new  situations. 

The  cutaneous  form  (Charbon;  malignant  pustule)  is  characterized 
by  the  formation  of  a  papule,  changing  into  a  vesicle,  surrounded  by 
an  edematous  area  (Figs.  42  and  43) ;  no  pus  is  discharged.  The  vesicle 
dries  up,  a  scab  forms,  central  necrosis  occurs,  the  black  central  core 
completing  the  typical  picture.  The  pain  ceases,  and  in  mild  cases  the 
slough  may  be  cast  off,  and  spontaneous  healing  occur.  In  severer 
cases,  lymphadenitis  and  angeioleucitis  develop,  toxemia  becomes 
profound,  and  death  may  ensue  in  a  fewT  days.  The  pulmonary  form 
(icoolsorter' s  disease)  is  of  slight  surgical  importance;  80  per  cent, 
of  patients  are  said  to  die  by  the  fifth  day.  The  intestinal  form  is 
characterized  first  by  symptoms  of  ptomain  poisoning;  then  by  hem- 
orrhages; and  finally  the  lodgement  of  the  bacilli  in  the  cutaneous 
capillaries  produces  a  widespread  carbunculoid  eruption  soon  followed 
by  death. 

Diagnosis. — Anthrax  is  to  be  distinguished  from  other  surgical 
infections  by  the  history  of  exposure  to  the  infection;  by  the  local 


st; 


ACUTE   TNFECflOUS  SURGICAL   DISEASES 


edematous  reaction,  with  central  Mack  core;  by  the  absence  of  pain 
and  suppuration;  and  finally  l»y  detecting  the  bacilli  in  smears  made 
from  the  lesion. 


\5* 


Fig.  41. — Anthrax  bacilli.  Spore  formation.  From  an  agar  culture  twenty-four 
hours  old.  About  the  margin  of  the  photograph  are  a  number  of  free  spores.  X  600. 
(Karg  and  Schmorl.) 


Fig.  42. — Anthrax  of  face. 
Episcopal  Hospital. 


Fig 


43. — Anthrax  of  face.    Black  slough 
in  center  of  edematous  area. 


Treatment. — Excision  should  be  done  when  possible,  as  is  usually  the 
case  when  an  extremity  is  affected.  Injections  of  pure  carbolic  acid 
around  the  lesion  (five  drops  in  each  puncture)  have  seemed  to  be 
beneficial  in  some  cases.  Pressure  on  the  pustule  is  to  be  avoided. 
Locally,  antiseptic  applications  are  indicated.  In  severe  cases  Bar- 
lach  (1908)  surrounds  the  lesion  by  a  circle  of  punctures  made  by  the 


GLANDERS  N< 

actual  cautery;  he  has  treated  23  cases  with  no  deaths.  Most  im- 
portant of  all,  however,  appears  to  be  the  use  of  Sclavo's  serum  (1897); 
in  many  cases  of  the  disease  (pulmonary  and  intestinal)  it  is  the 
only  remedy  available;  30  to  40  c.c,  in  divided  doses,  are  injected  at 
different  points  in  the  abdominal  wall.  This  dose  may  be  repeated,  if 
necessary,  the  following  day.  In  severe  cases  intravenous  injection 
should  be  tried  (Lawen,  190S).  By  these  means  the  mortality  has 
been  reduced  to  6  and  even  to  3  per  cent,  in  large  series  of  cases. 

Glanders  (Farcy),  due  to  the  B.  mallei  (Loffler  and  Schiitz,  1882), 
is  common  in  horses,  asses,  and  mules   (equinia);  sheep  and  goats 
are  also  affected.     From  these  lower  animals 
the  disease  is  sometimes  conveyed  to  man  by  «  \ 

the  spray  emitted  by  the  horse,  mule,  etc.,  •  /  \]\  b.  \^\ 

in    sneezing,   or   by    means  of  the   purulent  <  *    ^  ^  <  5  ^ 

discharge  from  other  sources.     Occupation  in        \\    jj  \W  ^     W 
stables    is    therefore    a   predisposing    cause.         [  N^"^     f^    j    x 
Invasion  occurs  by  inoculation  of  an  abrasion  •  \</v '^p     % 

of  the  skin  (farcy) ;  or  of  the  nasal  or  buccal        \       8v        J*  \ 
mucous    membrane    (glanders);    or    through  \    j>  '    A\ 

the  respiratory  or  digestive  tract.    The  result- 
ing infection  runs  an  acute  (very  rarely    a     gian'dera^B^mSs'mllleo! 
chronic)  course.     The  local  lesion  somewhat     (Abbott.) 
resembles  a  tubercle ;  the  regional  lymphatics  - 

are  affected  early,  and  dissemination  through  the  blood-stream  is 
rapid.  The  lesions,  wherever  situated,  are  specially  characterized  by 
their  tendency  to  rapid  suppuration.  Along  the  lymphatics,  small 
hard  nodules  (farcy  buds)  appear,  and  soon  suppurate.  In  the  lungs 
multiple  foci,  which  soon  suppurate,  are  produced.  A  diffuse  pustular 
eruption,  sometimes  mistaken  for  smallpox,  frequently  occurs  in  the 
skin  (Fig.  45).  In  the  subcutaneous  tissues  and  muscles,  hard,  movable 
nodules  appear,  especially  in  the  biceps,  flexors  of  forearm,  rectus 
abdominis,  and  pectoral  muscles;  the  nodules  soon  suppurate.  Bones 
may  be  invaded,  and  by  implication  of  joints  pyarthrosis  may  occur. 

Symptoms. — The  period  of  incubation  varies  from  three  to  seven 
days;  malaise  and  indefinite  typhoidal  symptoms  are  the  first  to 
appear.  In  glanders,  naso-pharyngeal  granulomas  are  the  earliest 
lesions,  with  ulcerations,  causing  sero-sanguineous  catarrh ;  then  pneu- 
monic signs;  and  finally  the  cutaneous  rashes,  and  subcutaneous  and 
muscular  nodes.  Leukocytosis  usually  is  not  marked.  In  farcy, 
the  skin  affected  becomes  intensely  inflamed;  farcy  buds  appear 
along  the  lymphatics  and  soon  suppurate;  while  the  later  symptoms 
resemble  the  last  stages  of  glanders. 

Diagnosis. — In  the  acute  cases  this  is  rarely  made  before  death. 
The  patient's  occupation,  microscopical  examination  of  the  discharges, 
and  a  negative  Widal  reaction,  are  factors  which  may  indicate  the 
nature  of  the  malady.  By  the  time  the  characteristic  nodes  appear, 
the  patient  is  beyond  the  reach  of  treatment.  In  animals  the  disease 
may  be  detected  by  the  "mallein  test"  (similar  to  the  tuberculin  test, 


88  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

p.  79).   .The  chronic  form  of  the  disease  resembles  the  late  stages  of 
syphilis. 

Prognosis.  The  disease  is  extremely  fatal  (85  to  90  per  cent,  of 
cases).     Death  occurs  in  from  one  to  three  weeks. 

Treatment.- — Isolation  should  he  immediate,  as  the  disease  is  easily 
conveyed  by  both  immediate  and  mediate  contagion.  If  an  extremity 
be  affected,  amputation  is  indicated.  Localized  lesions  elsewhere 
should  be  excised  when  possible;  at  least  they  should  be  opened  and 
treated  with  rigorous  antiseptic  methods.  Curettement  and  scrub- 
bing are  liable  to  disseminate  the  bacilli.  Hygienic  treatment  often 
is  all  that  is  available. 


Fig.  45. — Pustular  eruption  in  human  glanders.     (Dr.  Zeit's  case.) 

Gas  Gangrene.' — Gas  gangrene  is  a  form  of  acute  infection  almost 
invariably  observed  only  as  a  complication  of  severe  compound  frac- 
tures or  lacerated  wounds;  but  it  has  occasionally  followed  punctured 
wounds  or  even  mere  abrasions.  There  are  recognized,  according  to 
Weinberg  (1918),  more  than  forty  different  bacteria  as  causes;  but 
those  most  frequently  found  are  the  B.  perfringens  (known  also  as 
the  B.  aerogenes  capsulatus,  or  B.  welchii,  1892),  B.  sporogenes,  B. 
cedematiens  and  the  Vibrion  septique,  especially  that  first  named. 
The  B.  cedematiens  produces  no  gas,  but  causes  a  characteristic 
hard  white  edema  of  the  subcutaneous  tissues  and  skin. 

1  Among  the  numerous  synonyms  may  be  mentioned  traumatic  gangrene  (Renault, 
1840),  traumatic  spontaneous  emphysema  (Malgaigne,  1845),  gangrene  foudroyante 
(Chassaignac,  1853),  acute  purulent  edema  (Pirogoff,  1854),  erysipele  bronze 
(Velpeau,  1855).  The  malignant  edema  of  Brieger  and  Ehrlich,  said  by  some 
authorities  to  be  caused  by  a  specific  bacillus  (B.  cedematis  maligni),  is  a  closely 
analogous  if  not  indeed  an  identical  affection.  H.  Henry  (1917)  considers  the 
modern  B.  sporogenes  the  same  as  the  old  B.  cedematis  maligni. 


GAS  GANGRENE  89 

Gas  gangrene  is  rare  in  civil  surgery,  where  I  have  seen  only  3  eases 
in  nineteen  years;  but  during  the  German  war  it  has  been  very  fre- 
quent, largely  owing  to  the  character  of  the  soil  in  which  the  fighting 
took  place.  For  many  generations  this  has  been  highly  fertilized 
with  human  and  bovine  dejections,  so  that  fecal  contamination  of  the 
wounds  was  the  rule  rather  than  the  exception.  Two  conditions  are 
necessary  for  the  development  of  gas  gangrene:  (1)  the  presence  of 
the  gas-forming  bacteria  in  the  wounds;  and  (2)  conditions  favorable 
for  their  growth.  As  the  soldiers'  clothing  is  nearly  always  impreg- 
nated with  the  B.  perfringens,  the  lodgment  of  particles  of  clothing 


Fig.  46. — Emphysematous  gangrene.     Recovery  after  amputation  at  the 
shoulder-joint.     Episcopal  Hospital. 

in  the  wounds  is  especially  dangerous;  while  any  conditions  which 
deprive  the  tissues  of  oxygen  favor  the  growth  of  these  anaerobic 
bacteria.  Among  these  conditions  may  be  mentioned  mixed  infection, 
especially  with  the  streptococcus;  the  presence  of  a  hematoma;  and 
particularly  rupture  of  the  main  artery  of  the  limb.  Prolonged 
application  of  a  provisional  tourniquet  is  another  predisposing  factor. 
Bruised  and  lacerated  muscle  tissue  forms  a  very  favorable  nidus  for 
the  growth  of  these  anaerobic  bacteria,  owing  to  the  hemostatic 
properties  of  injured  muscle.  Indeed  it  has  been  claimed  that  gas 
gangrene  always  develops  primarily  in  muscular  tissue.  It  is  at 
any  rate  rare  in  the  feet,  head,  neck,  trunk  and  almost  unknown  in  the 


90  ACUTE  INFECTIOUS  &URGtcAL  DISEASES 

hands;  while  it  is  most  to  be  feared  in  the  muscular  parts  of  the  limbs, 
especially  the  thighs,  calves  of  the  legs,  buttocks,  upper  arms  and 
scapular  regions. 

Three  stages  of  the  disease  may  be  recognized,  though  the  duration 
of  each  stage  may  vary  greatly:  (1 )  The  wounds  may  be  contaminated 
by  bacteria  of  gas  gangrene  (as  shown  by  smear  and  culture)  without 
notable  clinical  symptoms,  especially  if  the  wounds  are  wide  and 
gaping.  Such  cases  do  well  after  excision  and  debridement  (p.  201) 
of  the  injured  tissues.  (2)  When  active  infection  is  already  present 
(usually  after  an  interval  of  twenty-four  to  forty-eight  hours  from 
the  time  of  injury),  attention  is  attracted  by  the  peculiar  odor  emitted 
from  the  wounds;  it  has  been  likened  to  the  odor  of  mice,  but  is  dis- 
tinctly sui  generis,  and  easily  recognized  when  once  experienced. 
The  patient  complains  of  a  sense  of  constriction  in  the  affected  limb, 
even  if  the  dressings  are  loose,  and  on  examination  the  part  is  found 
swollen,  tense  and  exquisitely  tender.  Such  tenderness  in  a  battle 
wound  is  almost  pathognomonic.  There  may  be  patches  or  large 
areas  of  bronzed  erysipelas  (the  color  is  believed  to  be  due  to  hemolysis) 
and  these  may  be  at  a  distance  from  the  wound.  At  this  stage,  still, 
very  wide  debridement  may  suffice,  unless  the  lesion  includes  a  fracture, 
or  injury  to  a  large  bloodvessel,  or  opens  a  joint,  when  amputation  is 
demanded.  (3)  The  stage  of  true  gas  gangrene  has  seldom  been  seen 
except  shortly  before  the  patient's  death;  the  subcutaneous  tissues, 
the  muscles,  the  intermuscular  planes,  and  perhaps  even  the  medulla 
of  bones  may  be  affected.  The  muscles  form  a  purplish,  pultaceous, 
stinking  mass;  they  are  spongy  to  the  touch,  and  foam  exudes  when 
they  are  compressed.  Exposed  surfaces  are  covered  with  an  ashen  or 
grayish  slough.  Emphysematous  crackling  extends  with  alarming 
rapidity  along  the  course  of  the  large  vessels;  the  skin  becomes 
dusky  and  mottled  in  appearance,  and  finally  the  vesications  and 
bulla?,  so  characteristic  of  fermentative  changes  in  already  mortified 
parts,  may  develop.  Incisions  into  the  swollen  and  boggy  tissues 
give  exit  to  frothy  fluid  and  malodorous  gases.  There  is  no  pus.  The 
usual  constitutional  symptoms  of  toxemia  (p.  69)  develop,  rapid 
respiration  being  especially  noted,  though  there  may  be  little  fever, 
and  the  pulse  sometimes  is  slower  than  normal.  Death  usually  ensues 
a  short  time  after  the  infection  reaches  the  trunk.  The  entire  course 
of  the  disease  may  extend  over  only  six  or  eight  hours.  While,  accord- 
ing to  Chalier  (1917),  the  gases  themselves  are  poisonous,  it  is  the 
bacterial  toxins  and  the  metabolic  products  of  muscle  destruction 
which  are  usually  held  responsible  for  death.  The  only  safe  treatment 
for  this  emphysematous  stage  is  immediate  amputation  high  above  the 
limit  of  disease.  The  amputation  should  be  done  by  the  einschnitt 
method  of  Esmarch  (p.  218),  called  in  France  the  guillotine  method  or 
amputation  en  savcisse;  this  method  exposes  the  least  possible  area 
to  re-infection  (not  unknown),  and  leaves  the  least  possible  granulat- 
ing surface  for  repair.  If  the  amputation  is  done  near  the  trunk,  no 
tourniquet  should  be  used,  but  the  main  vessels  should  be  ligated  and 


TETANUS  91 

divided  as  the  first  step.  In  cases  where  amputation  cannot  be  done, 
or  even  in  addition  to  amputation,  multiple  (150  to  200)  cautery 
punctures  should  be  made  through  the  deep  fascia,  as  advised  by 
Michaux  (1914)  and  others,  in  the  tissues  bordering  the  gangrenous 
area  as  well  as  in  this  itself.  Such  punctures  drain  longer  than  inci- 
sions by  the  knife.  Several  antitoxic  sera  for  gas  gangrene  have  been 
introduced,  notably  by  Bull,  of  New  York  City,  and  by  Weinberg,  of 
Paris.  Their  prophylactic  use  was  being  developed  when  the  war 
closed.  Therapeutically,  in  some  cases  their  effect  has  been  marvel- 
lous, one  or  at  the  most  two  injections  seeming  to  bring  back  the 
patient  from  the  verge  of  the  grave.  While  they  should  always  be 
used  if  available,  they  do  not  take  the  place  of  excision,  debridement 
or  amputation 

Tetanus  (Lockjaw). — This  disease,  characterized  by  tonic  and  clonic 
convulsions,  and  especially  by  locking  of  the  jaws,  is  caused  by  the  B. 
tetani  (Fig.  47),  discovered  by 
Nicolaier  in  1884,  and  obtained  in 
pure  culture  by  Kitasato  in  1889. 
The  bacillus  is  anaerobic  and  is 
found  especially  in  garden  soil, 
barnyards,  stables,  etc.  It  prob- 
ably normally  infests  the  intes- 
tinal tract  of  cattle,  and  is  re- 
deposited  with  their  dung.  So 
long  as  the  mucosa  of  their  gastro- 
intestinal tract  is  intact,  they  are 
not  liable  to  infection  by  this 
channel.  Horses  are  particularly 
susceptible.  Tetanus  appears  to 
be  endemic  in  certain  localities. 

T  i    ,.  i      ,,  i  Fig.  4/. — Tetanus     bacilli,    showing    spore 

Inoculation  OCClirS  Only  through  a  formation.     (Kitasato.) 

wound.    Cryptogenetic  (formerly 

called  idiopathic)  tetanus  is  that  form  in  which  the  wound  of  entrance 
cannot  be  discovered,  having  been  insignificant  in  extent,  or  being 
on  a  mucous  surface.  Wounds  contaminated  with  garden  soil,  street 
dust  and  especially  those  in  which  foreign  bodies  have  lodged,  are 
most  to  be  suspected  of  harboring  tetanus  bacilli ;  while  their  develop- 
ment is  favored  by  anaerobic  conditions  of  the  wound.  These  condi- 
tions are  found  in  punctured,  contused  and  lacerated  wounds.  A 
mixed  infection,  especially  with  saprophytic  bacteria,  is  favorable 
because  these  organisms,  being  aerobic,  absorb  all  available  oxygen, 
and  provide  anaerobic  conditions  for  the  tetanus  bacilli.  Tetanus  is 
seen  after  compound  fractures  and  gunshot  wounds;  during  the  puer- 
peral state,  when  inoculation  occurs  by  the  genital  tract;  in  the  new- 
born (tetanus  nascentium)  from  infection  of  the  umbilical  cord;  and 
not  infrequently  in  cases  of  extensive  burns.  Contagion  may  spread 
from  one  patient  to  another  by  the  medium  of  instruments,  dress- 
ings, etc.     Postoperative  tetanus  has  been  studied  by  Matas  (1909), 


02  ACUTE  INFECTIOUS  SURGICAL   DISEASES 

who  suggests  that  it  is  <lii<'  to  germs  of  tetanus,  latent  in  the  patient's 
intestinal  tract,  ingested  with  uncooked  food,  and  infecting  the  oper- 
ative wound  by  fecal  contact.  There  is  no  good  evidence  that  it  is 
due  to  the  use  of  infected  catgut. 

Pathology. — After  inoculation  there  is  an  incubation  period  aver- 
aging probably  about  nine  days,  but  which  may  vary  from  one  day  to 
eight  weeks  or  more;  yet  when  so  long  a  period  has  elapsed  it  is  not 
always  possible  to  exclude  a  more  recent  inoculation.  The  duration 
of  incubation  is  due  largely  to  the  distance  of  the  wound  from  the 
spinal  cord,  and  to  the  conditions  present  at  the  site  of  inoculation. 
Experimentally  the  bacilli  are  easily  destroyed  by  the  normal  tissues 
of  the  body;  but  if  these  structures  (phagocytes  and  bactericidal 
fluids)  are  engaged  in  combating  foreign  bodies  or  other  bacteria  as 
well,  then  the  tetanus  bacilli  begin  to  exert  their  influence  more 
promptly.  The  tetanus  bacilli  remain  in  the  primary  wound;  the 
disease  is  a  pure  toxemia;  extremely  rare  are  the  cases  where  the 
bacilli  are  found  in  the  blood,  lymph,  or  other  body  tissues.  The  local 
reaction  caused  by  the  bacilli  is  in  no  way  characteristic,  and  is  insig- 
nificant in  extent.  The  toxins  they  produce  are  alone  responsible  for 
the  symptoms  of  the  disease:  so  long  as  no  toxins  are  produced,  no 
evil  effects  are  observed  from  the  presence  of  the  bacilli  in  wounds; 
and  if  toxins  alone  are  introduced  they  produce  symptoms  identical 
with  those  seen  when  the  bacilli  are  present  and  multiplying  in  the 
wound.  The  toxins  produce  no  symptoms  until  they  are  transported 
to  the  spinal  cord;  and  they  reach  the  spinal  cord  only  by  travelling 
along  the  motor  nerves.  Toxins  are  absorbed  directly  by  the  nerves 
of  the  wounded  part  and  are  transported  through  them  to  the  spinal 
cord;  if  the  nerve  is  divided  the  toxins  will  ascend  as  far  as  the  section 
but  not  beyond.  Toxins  also  enter  the  circulation,  but  cannot  reach 
the  central  nervous  system  except  when  carried  to  the  peripheral 
ends  of  motor  nerves  and  absorbed  by  them.  Toxin  absorbed  from 
the  circulation  through  short  nerves  reaches  the  cord  sooner  than  that 
absorbed  through  long  nerves.  This  explains  the  early  appearance 
of  muscle  cramp  in  the  face  muscles  and  those  of  the  spine,  which 
may  occur  before  cramps  in  the  wounded  extremity. 

In  the  anterior  horns  of  the  cord,  congestion,  exudation,  and  ecchy- 
mosis  are  frequently  observed;  but  the  changes  are  not  pathognomonic 
for  tetanus.  When  once  the  cord  is  invaded,  the  infection  spreads 
from  segment  to  segment,  and  the  sensory  portions  are  affected 
directly.  The  toxin  appears  to  enter  into  chemical  combination 
with  the  nerve  tissue.  Tonic  contraction  of  the  muscles  is  caused  by 
irritation  of  the  motor  tracts;  while  the  implication  of  the  sensory 
portions  of  the  cord  renders  it  so  exceedingly  susceptible  to  stimulus, 
that  clonic  convulsions  are  often  superadded  to  the  tonic  spasms. 
Our  knowledge  of  the  pathology  of  tetanus  is  due  chiefly  to  the  work 
of  Marie  and  Morax  (1902),  and  of  Meyer  and  Ransom  (1903). 

Symptoms. — Vague  prodromal  symptoms  occasionally  are  noted. 
When  the  incubation  period  lasts  less  than  ten  days,  the  disease  is 


TETANUS 


93 


said  to  be  acute.  Sometimes  the  wound  seems  painful,  or  a  chill  may 
occur.  Usually  the  first  thing  noted  by  the  patient  is  a  stiffness  of  the 
jaws  (trismus)  or  a  painful  contraction  of  the  extensors  of  the  neck; 
occasionally  spasm  occurs  first  in  the  muscles  of  the  wounded  part 


Fig.   IS. — Opisthotonos  in  third  day  of  tetanus;  death  six  hours  later  in  convulsions. 
Note  also  sardonic  grin.     Episcopal  Hospital. 

[local  or  ascending  tetanus).  These  primary  symptoms  are  quickly 
followed,  usually  in  a  few  hours,  by  more  or  less  generalized  cramps, 
the  extensors  almost  always  overcoming  the  flexors.  Thus  the  feet 
are  fully  extended,  the  head  retracted,  and  the  back  arched,  so  that 
the  entire  body  may  be  supported  on 
the  occiput  and  the  feet  (opisthotonos) 
(Fig.  48);  emprosthotonos  is  the  term 
used  for  the  opposite  condition,  when 
the  action  of  the  flexors  predominates, 
and  the  body  is  bowed  forward;  pleuro- 
thotonos,  in  which  lateral  deviation  of 
the  spine  is  the  chief  feature,  is  extremely 
rare.  These  tonic  spasms  are  more  or 
less  continuous,  full  relaxation  rarely 
being  attained  at  any  time  during  the 
course  of  the  disease.  The  clonic  con- 
vulsions are  superadded  to  the  tonic 
spasms,  and  bring  on  again  exaggerated 
degrees  of  opisthotonos,  etc.  Then  the 
opisthotonos  relaxes,  and  until  again 
excited,  general  rigidity  is  all  that  re- 
mains; but  the  jaws  usually  are  persis- 
tently shut,  the  head  retracted  and  the 
back  arched.  The  spasms  are  exceedingly 
painful  and  terribly  exhausting.     They 

recur  without  regularity.  They  are  easily  aroused  by  a  draught  of 
air,  a  slamming  door,  jarring  of  the  bedstead,  etc.,  as  the  spinal  cord 
is  in  a  state  of  extreme  hyperexcitability.  Bronchorrhea  is  frequently 
troublesome,  and  hypostatic  or  inhalation  pneumonia  may  develop. 
Tonic  contraction  of  the  facial  muscles  produces  the  so-called  sardonic 


Fig.  49. — Risus  sardonicus,  per- 
sisting during  convalescence  from 
tetanus.  Aged  seven  years;  incu- 
bation ten  days.  From  a  patient 
in  the  University  Hospital  under 
the  care  of  the  late  Prof.  Ash- 
hurst. 


!)|  .1(7  TE  INFECTIOUS  SI  RGICAL  DISEASES 

grin.  This  may  persist  during  convalescence  (Fig.  49).  Respiration 
is  difficult  and  labored.  Asphyxia  is  frequently  threatened  in  the 
clonic  convulsions.  Spasm  of  the  diaphragm  causes  the  fearful  "girdle- 
pain."  The  abdominal  muscles  are  "as  hard  as  a  board."  Reten- 
tion of  urine  frequently  occurs,  and  constipation  is  extreme.  The 
recurring  convulsions  deprive  the  patient  of  sleep;  nourishment  can 
be  administered  only  with  the  greatest  difficulty;  the  mind  remains 
clear  to  the  end,  and  death  is  often  welcomed  by  the  patient  as  the 
only  relief.  High  fever  is  an  unfavorable  symptom;  at  death,  and 
afterwards,  the  temperature  rises  rapidly. 

Chronic  Tetanus. — This  term  is  used  in  two  senses:  (1)  For  cases 
with  an  incubation  period  of  more  than  ten  days.  (2)  For  those  in 
which  the  patient  survives  more  than  fifteen  days.  In  either  instance 
the  symptoms  are  less  severe.  Occasionally  permanent  contractures, 
especially  of  the  jaws,  persist  after  recovery. 

Cephalic  Tetanus. — Cephalic  tetanus  is  a  rare  form  due  to  a  wound 
of  the  head,  and  accompanied  by  facial  paralysis. 

Diagnosis. — This  must  be  based  on  the  suspected  wound  infection; 
on  the  early  occurrence  of  retraction  of  the  head  or  of  trismus;  on  the 
generalized  tonic  and  clonic  convulsions;  on  the  entire  absence  of 
delirium;  and  on  exclusion  of  all  other  diseases.  Tt  seldom  is  possible 
to  recover  the  bacilli  from  the  point  of  inoculation,  but  injection  of 
the  patient's  blood  serum  or  cerebrospinal  fluid  into  one  of  the  lower 
animals  may  cause  tetanic  convulsions. 

Prognosis. — This  is  bad.  The  general  mortality  is  about  60  per  cent. 
Anders's  figures  (1905)  showed  a  mortality  of  74  per  cent,  for  cases 
developing  in  less  than  ten  days;  and  of  8.5  per  cent,  for  those  which 
lasted  more  than  fifteen  days.  Jacobson's  statistics  (1906),  from  all 
the  cases  treated  in  various  hospitals  during  given  periods,  showed  a 
mortality  of  <S3.1  per  cent,  for  acute  and  of  43.6  per  cent,  in  subacute 
cases.  The  longer  the  period  of  incubation,  and  the  longer  life  is  pre- 
served after  the  symptoms  develop,  the  greater  is  the  chance  of 
ultimate  recovery.  With  early  diagnosis  and  prompt  and  efficient 
treatment,  the  mortality  of  acute  cases  should  be  reduced  to  20  per 
cent,  or  lower  (Ashhurst  and  John,  1913). 

Treatment. — Prevention  is  better  than  cure.  Extreme  care  must 
be  exercised  in  dressing  wounds  which  seem  predisposed  to  the  devel- 
opment of  tetanus.  Septic  punctured  wounds  should  be  opened  and 
treated  with  the  most  scrupulous  antisepsis.  Remove  all  foreign 
bodies  and  sloughs.  Swab  the  wround  with  3  per  cent,  alcoholic 
solution  of  iodin,  rinse  with  hot  peroxide  of  hydrogen,  and  pack 
lightly  with  gauze  soaked  in  the  iodin  solution.  Lacerated  and  con- 
tused wounds  must  be  even  more  freely  drained  than  where  no  prob- 
ability of  tetanic  infection  exists.  Inject  1500  units  of  tetanus  anti- 
toxin into  the  tissues  around  the  wound,  or  into  any  nerves  exposed 
in  the  wound;  and  repeat  this  injection  at  the  end  of  eight  or  nine  days, 
since  by  this  time  the  antitoxin  first  injected  will  have  disappeared, 
but  toxins  may  not  yet  have  been  produced. 


TETANUS  95 

When  the  disease  has  once  developed,  active  treatment  is  impera- 
tive. A  few  hours'  delay  in  recognizing  the  malady  and  in  instituting 
proper  relief,  may  render  cure  impossible.  Stiffness  of  the  jaws  is 
enough  in  a  suspicious  case  to  justify  the  use  of  heroic  measures. 
The  inexperienced  surgeon  frequently  is  thrown  off  his  guard  because 
the  patient's  mind  remains  so  calm  and  clear.  The  patient  should 
be  isolated  at  once  in  a  quiet,  cool,  darkened  room,  and  a  special  nurse 
should  be  placed  in  charge.  The  principles  of  treatment  are:  (1)  To 
remove  the  source  which  supplies  the  toxins  (i.  e.,  the  bacilli  still  in 
the  wound);  (2)  to  neutralize  toxins  already  formed;  (3)  to  depress 
the  functions  of  the  spinal  cord;  and  (4)  to  sustain  the  patient  by 
nourishment,  nursing,  etc. 

1.  The  first  indication  involves  care  of  the  wound,  which  is  the  same 
as  recommended  for  the  prevention  of  tetanus. 

2.  To  neutralize  the  toxins,  antitoxin  should  be  used.  This  is  supplied 
in  tubes  containing  1500  units  (5  c.c.)  and  3000  units  (10  c.c.)  each. 
It  is  evident  from  the  pathology  of  the  disease  that  it  is  quite  extrav- 
agant to  inject  it  hypodermically  or  even  intravenously.  The  only 
way  in  which  it  can  act  upon  the  toxins  ascending  from  the  wound  is 
when  it  is  brought  into  direct  contact  with  the  nerves  or  spinal 
cord.  If  used  subcutaneously  at  least  100,000  units  should  be 
administered  in  the  first  twenty-four  hours.  It  was  pointed  out 
by  Ashhurst  and  John  (1913)  that  antitoxin  injected  into  the  sub- 
arachnoid space  of  the  cord  probably  acts  directly  on  the  nerve 
roots,1  and  such  immediate  and  favorable  effects  from  the  repeated 
intraspinal  administration  of  antitoxin  have  been  observed  that 
I  think  it  should  be  employed  in  every  case.  Anesthesia  is  not 
necessary,  though  often  desirable.  Chloroform  is  better  than  ether. 
The  hollow  needle  is  inserted  between  the  second  and  third  lumbar 
spines  (p.  158),  and  a  few  cubic  centimeters  of  the  subarachnoid 
fluid  are  drawn  off;  and  from  3000  to  10,000  units  of  antitoxin,  diluted 
with  warm  saline  solution,  are  slowly  injected  by  syringe  or  gravity. 
If  the  site  of  inoculation  is  on  the  upper  extremity  or  head,  the  foot 
of  the  table  may  be  raised  to  allow  the  antitoxin  to  gravitate  toward 
the  medulla.  If  no  marked  improvement  follows  the  subarachnoid 
injection,  within  six  or  eight  hours,  about  18,000  to  20,000  units  of 
antitoxin  should  be  administered  intravenously.  The  intraspinal 
and  intravenous  injections  should  be  repeated  daily,  until  the  disease 
is  definitely  controlled.  Since  the  general  adoption  of  intraspinal 
therapy,  there  has  been  less  reason  for  intraneural  injections;  all  the 
nerves  may  be  reached  simultaneously  through  the  spinal  route. 

3.  To  depress  the  functions  of  the  spinal  cord  drugs  may  be  given 
by  mouth  if  the  patient  can  swallow,  or  by  the  rectum;  hypodermic 
administration  is  best  when  possible.  These  drugs  should  be  admin- 
istered in  doses  sufficient  to  produce  some  effect;  10  to  20  grains  of 
chloral  hydrate,  and  twice  as  much  bromide  of  potassium,  may  be 

1  This  was  confirmed,  experimentally,  by  Park  and  Nicoll  (1914). 


96  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

giveD  as  often  as  every  two  or  three  hours;  more  should  l>e  given  if  the 
patient  requires  it,  and  less  if  it  proves  to  be  sufficient  to  relieve 
the  pain  and  diminish  the  rigidity.  Morphin  is  of  very  little  value. 
Chloretone  has  given  gratifying  results  (Hutchings,  1909).  It  is 
administered  by  mouth  or  rectum  in  doses  of  from  30  to  60  grains, 
dissolved  in  whisky  or  hot  olive  oil. 

Treatment  by  intraspinal  injections  of  magnesium  sulphate,  intro- 
duced by  Blake  of  New  York  in  1906,  is  based  on  the  anesthetic  effect 
of  this  drug,  when  injected  into  the  subarachnoid  space  (Meltzer, 
I  !>().">).  It  acts  as  a  spinal  depressant,  and  should  not  be  used  as  a  sub- 
stitute for  antitoxin.  Solutions  of  12.5  to  25  per  cent,  strength  are 
employed,  and  5  to  10  c.c.  are  used  at  each  injection  (1  c.c.  of  the 
drug  for  every  25  pounds  of  body  weight).  It  is  a  dangerous  remedy, 
and  several  deaths  have  been  reported  following  its  employment. 

Carbolic  acid  injection*,  introduced  by  Bacelli  (1888),  are  supposed 
by  some  to  have  a  specific  action  in  tetanus.  Subcutaneous  injec- 
tions of  \  per  cent,  watery  solution  are  administered,  every  one 
or  two  hours,  preferably  along  the  spine,  until  80  or  100  eg.  are 
given  in  twenty-four  hours,  watching  for  constitutional  symptoms 
of  carbolic  acid  poisoning.  Experimental  evidence  (Camus,  1912) 
shows  this  treatment  to  be  useless,  but  clinically  some  good  results 
are  reported. 

4.  The  nursing  of  the  patient  is  very  important.  Clear  the  bowels  by 
a  brisk  purge  early  in  the  disease;  watch  for  retention  of  urine;  guard 
against  bed-sores.  Enforce  feeding,  by  the  stomach  tube  passed  under 
a  general  anesthetic  if  necessary. 

Hydrophobia  (Rabies,  Lyssa). — This  disease,  whose  exact  cause 
is  unknown,  is  characterized  by  clonic  spasms,  especially  of  the  faucial 
and  respirator}'  muscles;  it  results  from  inoculation  with  the  virus 
contained  in  the  saliva  of  rabid  animals,  notably  dogs,  wolves,  cats 
(also  foxes,  sheep,  goats,  pigs,  skunks,  deer,  etc.).  Any  mammalian 
may  be  affected.  It  is  disputed  that  it  is  .ever  conveyed  from  man  to 
man.  Though  infection  occurs  in  the  vast  majority  of  cases  by  bites, 
it  may  also  occur  through  scratches  by  claws  infected  with  saliva,  or 
by  an  animal  licking  an  existing  wound.  Wolf  bites  are  most  dan- 
gerous, because  it  is  said  the  hands  and  face,  unprotected  by  clothing, 
are  usually  bitten;  and  because  the  sharper  teeth  more  readily  pene- 
trate protected  parts.  It  is  possible  that  the  virus  may  be  partly 
wiped  off  the  teeth  of  animals  by  passing  through  clothing. 

The  disease  is  found  in  dogs  in  two  forms,  the  furious  and  the 
paralytic.  In  the  former,  the  dog  is  at  first  sullen,  retiring  to  his 
kennel,  and  looking  askance  at  every  one;  after  several  hours  he 
becomes  exceedingly  fidgety,  continually  shifting  his  posture;  suddenly 
he  becomes  irritable,  with  a  snapping  bark,  an  unsteady  and  staggering 
gait;  the  tongue  lolls  from  his  mouth,  swollen  and  red;  the  saliva  is 
profuse  and  viscid;  there  is  loss  of  appetite  and  presence  of  thirst. 
Later,  paralysis  of  the  extremities  occurs,  breathing  and  deglutition 
become  spasmodic,  and  convulsions  bring  on  death.    In  the  paralytic 


HYDROPHOBIA  97 

form,  the  disease  passes  at  once  from  the  sullen  to  the  paralytic  stage; 
the  dog  is  shy  and  melancholic;  there  is  no  disposition  to  bite;  he  is 
haggard  and  suspicious;  has  no  fear  of  water,  but  does  not  drink;  the 
tongue  lolls,  the  saliva  dribbles,  breathing  is  difficult  and  laborious; 
and  tremors,  vomiting,  and  convulsions  precede  death  (Youatt; 
quoted  by  Forbes,  1888). 

Pathology. — The  virus,  entering  the  wound  with  the  saliva,  and 
probably  derived  from  the  salivary  glands,  is  absorbed  by  the  nerves 
of  the  bitten  part  (Di  Vestea  and  Zagari,  1887),  and  travels  by  them 
to  the  spinal  cord;  whether  some  toxin  alone,  or  the  infective  agent 
itself  is  thus  transmitted,  is  still  unknown.  Some  of  the  virus  may 
travel  through  the  neural  lymphatics.  The  virus,  after  reaching  the 
cord,  travels  up  it  to  the  medulla,  cerebellum,  and  cerebrum;  it  also 
travels  out  along  the  spinal  and  cranial  nerves,  and  in  this  way  reaches 
the  salivary  glands  of  the  patient,  especially  the  submaxillary  and 
sublingual;  the  saliva  becomes  highly  infectious.  After  death  there 
are  found  in  the  cerebrum,  cerebellum,  medulla,  and  cord,  and  also 
in  the  salivary  glands,  various  degenerative  changes,  especially  marked 
in  that  part  of  the  cord  which  receives  the  nerves  of  the  bitten  part. 
The  most  important  microscopic  changes  are  in  certain  of  the  per- 
ipheral ganglia  and  in  the  hippocampal  convolution.  Van  Gehuchten 
and  Nelis  in  1900  found  changes,  seen  best  in  the  ganglia  of  the  vagus 
and  sympathetic  nerves,  consisting  in  proliferation  of  the  endothelial 
cells  lining  the  capsule  of  the  ganglion,  and  filling  up  the  spaces  between 
the  capsule  and  the  proper  cells  of  the  ganglion.  Negri  (1903)  found 
in  the  pyramidal  cells  of  the  cornu  Ammonis,  and  in  Purkinje's  cells 
in  the  cerebellum,  certain  cell  inclusions  which  he  regarded  as  para- 
sites and  the  cause  of  the  disease.  Nearly  all  observers  admit  that 
these  ganglionar  changes  and  the  presence  of  Negri  bodies  are  pathog- 
nomonic of  rabies;  they  are  found  in  other  diseases  only  with  the 
greatest  rarity;  but  many  dispute  Negri's  claim  that  the  bodies 
described  by  him  are  parasites,  and  deny  that  they  are  the  cause  of 
the  disease.  Rambaud  (1907)  points  out  that  their  distribution  is 
not  what  would  be  expected  of  the  specific  cause  of  rabies;  that  the 
virus  passes  through  filters  which  arrest  the  Negri  bodies  (Park 
thinks  this  not  a  valid  objection) ;  and  that  protozoa  survive  tempera- 
tures (45°  C.)  which  readily  render  the  rabic  virus  inert. 

Symptoms. — After  inoculation,  there  is  a  period  of  incubation, 
varying  from  four  or  five  days  up  to  several  months  or  a  year.  The 
average  period  in  man  is  forty  days  (Ravenel,  1901).  Incubation  is 
shortest  following  bites  of  the  face  and  other  exposed  parts,  also  fol- 
lowing wolf  bites.  The  original  wound  usually  has  firmly  healed  long 
before  any  symptoms  arise.  The  course  of  the  disease  was  described 
by  Virchow  as  embracing  three  stages:  (1)  The  first  stage,  which  may 
be  absent,  but  which  usually  lasts  from  a  few  to  twenty-four  hours. 
There  is  malaise,  lassitude,  headache,  twitching  of  the  throat,  stiff- 
ness of  the  neck,  a  feeling  of  suffocation,  and  rarely  slight  delirium. 
There  is  seldom  any  abnormal  sensation  in  the  wound.  During  this 
7 


98  ACUTE  INFECTIOUS  SURGICAL   DISEASES 

stage  the  virus  probably  is  ascending  the  cord.  (2)  The  second 
stage  is  evidenced  by  increasing  stiffness  and  pain  in  the  tongue, 
throat,  and  jaw  muscles;  there  is  dysphagia,  dryness,  and  great 
thirst;  profuse  salivation,  the  saliva  being  exceedingly  tenacious  and 
viscid;  this  necessitates  repeated  hawking  which  has  been  fancifully 
likened  to  the  bark  of  a  dog.  Violent  spitting  is  exceedingly  charac- 
teristic. The  patient  is  fearful  of  infecting  those  about  him.  Speech 
is  difficult,  being  often  choked  off  by  gasps  and  sobs  due  to  pharyngeal 
and  laryngeal  spasm.  Swallowing  becomes  impossible,  the  sight  of 
food  or  liquids,  and  sometimes  the  very  sound  of  running  water, 
bringing  on  renewed  paroxysms.  The  special  senses  become  pre- 
ternaturally  acute;  according  to  Kambaud,  the  slightest  draught 
of  air,  as  breathing  gently  on  the  patient,  always  produces  faucial 
spasm.  General  convulsions  ensue;  there  is  high  temperature,  rapid 
pulse,  and  poly  nuclear  leukocytosis.  The  urine  is  deficient;  it  may 
contain  albumin  or  sugar.  The  mind  seems  in  terrific  dread,  in 
unutterable  despair,  or  furious  anger.  Insane  impulses  and  delusions 
are  not  uncommon;  the  staring  eye,  tensely  drawn  mouth,  with 
bloody  foam  on  the  lips,  and  haggard  countenance  precede  mania, 
which  closes  the  second  stage.  The  entire  duration  of  this  frightful 
scene  may  be  twenty-four  to  forty-eight  hours;  and  death  from 
asphyxia  in  a  convulsion  is  frequent.  (3)  The  third,  or  paralytic  stage 
is  evidenced  by  exhaustion  succeeding  to  mania  and  convulsions: 
saliva  dribbles  from  the  hanging  mouth,  the  tongue  lolls,  and  a  horrible 
gurgling  in  the  throat  portends  dissolution  (Forbes,  1881).  The  entire 
course  of  the  disease  may  be  run  in  sixteen  hours,  or  it  may  last  four 
or  five  days;  seldom  longer.  In  rare  cases  the  furious  stage  is  entirely 
absent,  the  disease  resembling  the  paralytic  type  seen  in  dogs. 

Diagnosis. — This  affection,  which  is  exceedingly  rare,  is  distin- 
guished from  pseudo-rabies  (hysteria),  by  the  history  of  a  bite  from 
a  truly  rabid  animal;1  by  the  period  of  incubation,  which  is  never  less 
than  four  days;  and  by  the  almost  invariably  fatal  termination  within 
ten  days.  In  hysteria  the  symptoms  are  often  immediate,  the  barking 
and  hydrophobia  are  absurdly  exaggerated,  the  dog  is  not  mad,  and 
death  does  not  occur.  Tetanus  is  due  to  a  wound,  not  a  bite;  there 
is  no  excitement,  fury  or  mania;  the  convulsions  are  tonic  more  than 
clonic;  the  jaws  are  firmly  shut  and  cannot  be  opened;  there  is  no 
spasm  of  the  tongue  and  fauces.  Tetanus  is  a  quiet  disease;  apart 
from  gritting  of  the  teeth  during  convulsions,  the  patient  makes  no 
noise.    Rabies  is  a  furious  and  noisy  disease. 

1  To  determine  whether  or  not  the  animal  is  rabid,  it  should  not  be  killed 
immediately,  but  should  be  kept  under  observation  for  several  days,  or  at  least 
until  the  clinical  signs  are  noted  by  a  competent  veterinarian.  If  such  is  not  avail- 
able, the  dog's  head  should  be  cut  off  with  an  aseptic  knife,  and  sent  to  a  competent 
veterinarian  or  pathologist,  who  will  determine  from  the  microscopical  appear- 
ances of  the  plexiform  ganglion  and  cerebrum,  whether  or  not  the  animal  was 
afflicted  with  rabies.  This  fact  may  also  be  determined  by  inoculations  into  other 
animals,  but  this  method  may  take  several  weeks, 


HYDROPHOBIA  99 

Prognosis. — It  Is  now  said  that  from  10  to  15  per  cent,  of  those  bitten 
by  rabid  animals  are  liable  to  develop  the  disease;  it  was  formerly 
claimed  by  Pasteur  and  his  followers  that  the  incidence  was  much 
higher,  even  as  much  as  75  per  cent.  Not  only  is  it  an  unusual  disease 
in  man,  but  it  is  by  no  means  common  in  dogs  and  other  animals. 
It  is  most  frequent  in  France,  Germany,  and  Russia;  it  is  very  infre- 
quent in  Great  Britain  where  there  are  extremely  stringent  quaran- 
tine laws  against  the  importation  of  dogs;  and  almost  unknown  in 
Norway  and  Australia.  Most  surgeons  never  see  a  single  case.  I 
never  saw  one.  Our  entire  knowledge  of  the  disease  is  due  largely  to 
veterinarians  and  to  directors  of  Pasteur  Institutes.  The  disease 
when  it  really  does  occur  is  frightfully  fatal.  There  are  a  very  few 
well  authenticated  cases  of  recovery,  accepted  as  such  by  competent 
critics. 

Treatment. — This  must  be  both  preventive  and  curative.  The  former 
includes  police  regulation  of  dogs  and  other  domestic  animals,  as  well  as 
ordinary  surgical  treatment  for  a  poisoned  wound,  and,  if  the  patient 
wishes,  the  so-called  Pasteur  treatment  by  preventive  inoculation.  As 
soon  as  the  wound  is  received,  constriction  should  be  applied  on  its  proxi- 
mal side,  to  prevent  possible  absorption;  and  a  cupping  glass  should  be 
applied  to  suck  out  as  much  of  the  virus  as  possible.  In  emergency, 
the  patient  should  suck  the  wound  with  his  own  mouth,  spitting  out 
the  blood  thus  extracted.  The  best  antiseptic,  according  to  Rambaud, 
is  corrosive  sublimate  (1  to  1000);  the  compound  tincture  of  iodin  is 
also  good;  lemon  juice,  which  is  an  excellent  antidote  experimentally, 
may  be  used  in  emergency.  Caustics  are  worthless,  unless  heat  is 
used;  and  when  available  antiseptics  are  better  than  heat. 

The  Pasteur  treatment  is  based  on  the  theory  that,  even  during  the 
period  of  incubation,  inoculation  with  extremely  attenuated  virus, 
whose  strength  is  gradually  increased,  will  be  sufficient  to  immunize 
the  patient  against  the  disease.  The  attenuated  virus  is  obtained 
from  the  spinal  cords  of  rabbits  dead  of  hydrophobia;  the  quantity 
(not  the  quality)  of  the  virus  in  the  cords  gradually  diminishes  in 
dry  air.  The  first  inoculation  is  made  with  an  emulsion  of  a  cord 
from  a  rabbit  dead  twelve  to  fourteen  days,  and  the  course  of  treat- 
ment extends  over  about  two  weeks.  There  is  no  doubt  that  in  the 
vast  majority  of  cases  inoculation  of  healthy  animals  according  to 
this  system  will  immunize  them  against  rabies;  but  to  conclude  from 
this,  that  inoculation  of  patients  already  infected  will  also  be  efficient, 
is  not  logical.  From  practical  experience,  however,  it  may  be  said 
that  there  is  no  good  reason  to  doubt  that  inoculation  according  to 
Pasteur's  method,  under  the  latter  circumstances,  has  rendered  most 
of  the  patients  so  treated  immune.  But  it  must  not  be  forgotten  that 
the  vast  majority  of  patients  treated  in  Pasteur  Institutes  never 
would  have  developed  rabies  under  any  circumstances;  many  of 
them  are  bitten  by  animals  that  are  not  rabid;  and  therefore  their 
inoculation  in  most  instances  is  perfectly  useless.  Moreover,  there 
is  not  a  shadow  of  doubt  that  in  a  few  well  authenticated  cases  no 


100  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

Immunity  has  been  procured  by  the  inoculations,  the  patients  sub- 
sequently developing  and  dying  from  the  disease;  and  it  has  even 
been  open  to  suspicion  that  these  very  patients  might  have  been 
among  that  large  number  who,  even  without  the  inoculations,  never 
would  have  developed  the  disease— in  other  words,  that  the  danger 
of  contracting  rabies  as  the  result  of  the  inoculations,  though  very 
remote,  is  not  altogether  imaginary.  The  actual  mortality  attending 
the  Pasteur  treatment  is  given  as  less  than  1  per  cent.;  but  as  from 
these  statistics  it  is  customary  to  exclude  all  those  patients  who 
develop  rabies  within  fifteen  days  after  the  last  inoculation  (Rambaud), 
the  number  of  those  in  whom  immunity  is  actually  produced  is  con- 
siderably less  than  would  appear  if  this  fact  were  not  taken  into  con- 
sideration. Before  a  surgeon  recommends  the  preventive  treatment 
by  inoculation  he  should,  I  think,  place  all  these  facts  plainly  before 
the  patient;  and  if  the  patient  wishes  to  take  this  very  remote  risk, 
and  the  surgeon  is  convinced  that  he  was  infected  by  a  rabid  animal, 
no  time  should  be  lost  in  having  this  treatment  instituted. 

The  curative  treatment  is  nearly  hopeless.  Hyoscin  and  curare, 
hypodermically,  are  the  best  drugs;  chloral  and  morphin  have  little 
effect.  Proctoclysis  of  tap  water,  with  large  doses  of  bromides  by 
the  rectum,  may  be  tried.  Amyl  nitrite  or  chloroform  may  be  used 
for  the  convulsions.     The  saliva  should  be  sterilized. 


CHAPTER    IV. 
TUMORS. 

In  studying  the  inflammatory  process  it  was  seen  that  the  local 
reaction  induced  was  usually  sufficient  to  overcome  and  destroy  the 
origin  of  the  trouble;  in  the  case  of  the  infectious  granulomas,  instead 
of  an  efficient  reaction,  the  indications  of  inflammation  were  found  to 
be  very  slight,  and  cellular  proliferation  was  the  main  characteristic 
of  the  process.  Yet  in  both  these  instances  the  cell  proliferation  was 
incontestably  in  the  nature  of  a  reaction  to  external  stimulus.  In 
tumors  we  find  a  pathological  process  characterized  by  purposeless, 
more  or  less  unlimited,  cellular  proliferation  of  unknown  cause,  pro- 
ducing practically  no  reaction  in  surrounding  tissues.  The  cells  of 
tumors  seem  to  be  a  law  unto  themselves:  they  do  not  follow  the 
ordinary  processes  which  subserve  the  purposes  of  the  organism  as 
a  whole;  their  only  function  appears  to  be  proliferation,  and  this 
they  evince  without  discoverable  purpose  or  known  cause. 

For  an  understanding  of  tumor  processes  a  knowledge  of  embry- 
ology is  necessary,  because  the  most  logical  classification  of  tumors 
which  has  yet  been  proposed  (Adami,  1902) x  is  that  based  on  their 
histogenetic  characteristics,  and  because  the  ultimate  cause  of  tumor 
formation  seems  to  lie  in  inherent  characteristics  of  the  cells  them- 
selves, not  in  stimulus  from  without  nor  in  relief  from  constraint  by 
surrounding  structures. 

Definition. — This  is  difficult,  because  the  cause  of  tumors  is  not 
known;  a  definition  therefore  has  to  be  formed  solely  from  the  objective 
characteristics  of  fully  formed  tumors.  Adami  accepts  as  satisfactory 
the  statement  of  C.  P.  White  that  "a  tumor  is  a  mass  of  cells,  tissues, 
or  organs  resembling  those  normally  'present,  but  arranged  atypically. 
It  groics  at  the  expense  of  the  organism  without  at  the  same  time  sub- 
serving any  useful  function." 

GENERAL  CHARACTERISTICS  OF  TUMORS. 

The  word  tumor  means  a  swelling,  and  all  tumors  are  character- 
ized by  a  more  or  less  localized  swelling,  which  usually  is  both  visible 
and  palpable.  Tumors  may  be  multiple  or  single,  may  occur  at  any 
age,  and  in  any  situation. 

Form. — A  tumor  growing  on  the  surface  of  the  body  assumes  a 
typically  rounded  form  (Fig.  50) ;  one  in  the  internal  organs,  or  beneath 

1  In  the  following  paragraphs  the  teachings  of  Adami,  and  sometimes  his  words, 
have  been  closely  followed. 

(101) 


102 


//    MORS 


a  resistant  fascia,  or  compressed  by  other  parts  of  the  body  will  spread 
in  the  direction  of  least  resistance;  tumors  may  thus  become  irregular 

in  form  (nodular,  papillary, etc.). 
Consistency  varies  greatly,  being 
dependent  upon  the  type  of  tumor: 
fatty  tumors  are  soft;  bony  and 
cartilaginous  are  hard;  fibromas 
and  are  more  or  less  firm.  Rate  of 
Growth:  This  is  usually  slow,  the 
increase  in  size  being  measured 
by  months  or  years  rather  than 
by  weeks  or  days;  in  general,  the 
more  rapid  the  growth,  the  worse 
the  prognosis.  Slowly  growing 
tumors  seem  to  provoke  a  feeble 
reaction  in  the  surrounding  tis- 
sues, so  that  they  become  sur- 
rounded by  a  more  or  less  well 
defined  capsule;  those  of  rapid 
growth  extend  into  normal  tissues 
in  various  directions  before  a  cap- 
sule can  be  formed.  Manner  of 
Growth:  Growth  occurs  simul- 
taneously in  all  parts  of  a  tumor, 


Fig.  50. — Lipoma  of  right  arm. 


not  only  at  the  periphery  or  in  the  center,  though  in  certain  tumors 
growth  at  one  place  is  much  more  marked  than  at  others.  The  more 
rapid  the  growth,  the  more 
apt  are  the  central  cells  to  be 
squeezed  out  of  existence,  and 
therefore  in  such  tumors  cen- 
tral degeneration  is  common, 
leading  at  times  to  cyst  for- 
mation. Size  varies  so  greatly 
that  no  clear  statement  can 
be  made  (Figs.  51  and  52). 

Malignancy.  —  From  the 
above  it  is  evident  that  cer- 
tain tumors  are  less  benign 
than  others.  Even  tumors 
recognized  as  clearly  benign 
may  be  dangerous  from  their 
size  or  position.  The  size  of 
a  tumor  may  impair  the 
patient's  health  by  requiring 
an  extraordinary  amount  of 
nourishment;  its  position, 
even  if  small,  may  threaten 
life,  as  in  growths  of  the  larynx  threatening  suffocation,  in  the  ali- 
mentary canal  causing  obstruction,  or  in  the  brain  causing  pressure 


Fig.  51. — Papilloma  of  fact 


THEORIES  OF  TUMOR  FORMATION 


103 


on  vital  centers.  But  tumors  comparatively  small  in  size  and  innocu- 
ous in  position  may  by  their  inherent  characteristics  be  exceedingly 
dangerous  to  life.  These  characteristics  are  (Adami):  Embryonic 
character  of  the  tumor  cells,  leading  to  rapid  growth;  this  in  turn  gives 
the  surrounding  tissues  no  opportunity  to  encapsulate  the  growth, 
with  the  result  that  infiltration  of  the  surrounding  tissues  occurs,  this 
infiltration  extending  far  beyond  the  limits  visible  to  the  naked  eye 
or  discoverable  by  palpation.  Metastasis:  Some  of  the  tumor  cells  by 
their  rapid  growth  may  break  into  bloodvessels  and  be  carried  by  the 
blood  to  the  nearest  set  of  capillaries,  and  may  even  pass  through 
these  (pulmonic,  hepatic)  and  enter 
the  next  set,  in  either  situation 
lodging  and,  imless  killed  by  the 
tissues  of  the  part  in  which  they  are 
arrested,  giving  rise  there  to  new 
growths  {metastases)  similar  to  the 
original  tumor.  (It  is  held  by 
Orth  and  certain  other  pathologists 
that  normal  cells  surrounding  evi- 
dently malignant  cells  may  become 
infected  by  the  latter,  and  them- 
selves aid  in  the  formation  of  the 
tumors.  I  think  it  is  more  reason- 
able to  consider,  with  Ribbert, 
Adami,  and  others,  that  metastases 
are  due  to  the  proliferation  solely 
of  cells  which  have  been  trans- 
ported from  the  primary  tumor.) 
The  tendency  to  central  degenera- 
tion and  cyst  formation  has  already 
been  alluded  to;  in  addition,  super- 
ficial parts,  those  furthest  removed 
from  the  blood-supply,  whether  on 
mucous  or  cutaneous  surfaces,  tend 
to  sloughing  and  ulceration.  These 
malignant  tumors,  moreover,  tend 

to  return  after  removal  {recurrence),  either  because  this  was  incom- 
plete in  the  first  place,  or  because  other  previously  normal  cells  become 
anarchistic  in  their  turn.  Further,  malignant  tumors  produce  cachexia; 
this  is  not  in  any  sense  a  specific  cachexia,  but  is  caused  by  the  drain 
on  the  natural  resources  of  the  body  by  the  tumor,  by  anemia  due  to 
hemorrhages  from  its  ulcerated  surface,  by  toxemia  through  absorp- 
tion, or  by  intoxication  from  perverted  metabolism. 


Fig.  52. — Excision  of  right  clavicle  for 
alveolar  sarcoma,  March  3,  1894,  at  age 
of  nineteen  years.  Recurrent  growth  re- 
moved April  20,  1895.  Present  recurrence 
noticed  September  1896.  Grew  very  rap- 
idly after  April,  1897.  From  a  patient  in 
the  University  Hospital  under  the  care  of 
the  late  Prof.  John  Ashhurst,  Jr. 


THEORIES  OF  TUMOR  FORMATION. 

Most  of  the  theories  in  favor  at  the  present  day  account  only  for  one 
or  two  types  of  tumor.     Cohnheim's  theory  (1877-80)  is  to  the  effect 


104  TUMORS 

t  hat  during  fetal  life  certain  groups  of  cells  become  displaced  from  their 
normal  site,  remain  undeveloped  and  Latent  (cell  "rests")  until  some 
future  period  of  adult  life,  and  then  for  some  unknown  cause  begin 
to  proliferate  and  form  a  tumor;  this  theory  accounts  very  well  for 
tumors  of  distinctly  fetal  origin  (teratomas),  hut  there  are  many  other 
tumors  which  under  no  circumstances  can  be  considered  due  to  cell 
rests.  Ribbert's  theory  (1904-06),  a  modification  of  ('olmheim's,  sup- 
poses that,  besides  fetal  displacement,  also  post-natal  displacement 
of  nests  of  cells  may  occur;  but  that  proliferation  of  such  displaced 
cells  is  not  due  to  stimulation  from  without  nor  to  any  inherent 
qualities  of  the  cells  themselves,  but  to  lack  of  restraint  by  the  sur- 
rounding tissues.  Yet,  in  the  process  of  regeneration  (p.  29)  cells 
exhibit  such  qualities  in  marked  degree,  yet  no  tumor  results  except 
in  most  exceptional  instances.  Parasitic  Theory:  This  is  based 
chiefly  on  observations  which  tend  to  show  the  infectiousness  of  cer- 
tain malignant  tumors;  such  tumors  (carcinoma  and  sarcoma)  may 
be  transplanted  from  animal  to  animal,  their  virulence,  if  it  may  be 
so  called,  being  markedly  increased  by  passing  them  through  series 
of  susceptible  animals;  and  in  many  such  tumors  parasites  of  various 
kinds  have  been  found.  But  the  parasites  are  of  various  kinds,  their 
etiological  value  has  not  been  proved,  and  even  if  it  were,  this  theory 
would  explain  the  growth  of  only  one  class  of  tumors — the  malignant. 
This  reduces  us,  therefore,  to  the  theory  that  the  origin  of  tumors  lies 
in  perverted  habits  of  the  cells  themselves,  however  it  may  be  aided 
by  the  abnormal  position  of  the  cells  (Cohnheim),  by  their  release 
from  restraint  (Ribbert),  or  by  their  stimulation  by  parasitic  forms  of 
life.  The  utmost  that  we  definitely  know  of  tumor  cells  is,  as  Adami 
puts  it,  that  they  have  gained  the  habit  of  grouih,  and  have  lost  that  of 
function. 

CLASSIFICATION  OF  TUMORS. 

Functional  development  of  cells  necessitates  their  specialization. 
The  most  undeveloped  cells  are  said  to  be  toti-potential  (capable  of 
everything) ;  more  developed  cells  are  pluri-potential  (capable  of  more 
than  one  thing) ;  while  cells  which  are  most  developed  are  uni-yotential 
(capable  of  only  one  thing)  (Barfurth).  Basing  his  ideas  of  the 
nature  of  tumors  on  the  inherent  properties  of  the  cells  themselves, 
Adami  recognizes  three  main  groups  of  tumors,  according  to  whether 
the  tumor  arises  (1)  from  absolutely  undifferentiated  (toti-potential) 
embryonal  cells,  (2)  from  partially  differentiated  (pluri-potential) 
embryonal  cells,  or  (3)  from  uni-potential  cells,  that  is,  cells  which 
can  form  only  one  type  of  tissue.  The  first  class  (Teratoma)  is  derived 
from  cells  which  might  possibly,  at  a  later  period,  be  developed  into 
any  form  of  tissue  or  any  organ,  or  even  into  a  complete  individual. 
The  third  class  (Blastoma)  is  derived  from  cells  which  (before  the 
tumor  originates)  have  so  far  developed  that  they  can  give  rise  to 
only  one  form  of  tissue,  e.  g.,  connective  tissue  cells  can  produce  only 
connective  tissue  tumors,  epithelial  cells  can  produce  only  epithelial 


CLASSIFICATION  OF  TUMORS 


105 


tumors,  etc.  The  second  or  intermediary  type  of  tumor  (Terato- 
blastoma)  is  derived  from  cells  only  so  far  differentiated  that  they  can 
produce  more  than  one  form  of  tissue,  but  not  all  forms  (Fig.  53). 
Tumors  composed  only  of  one  tissue  are  rare. 


Fig.  53. — Diagrammatic  representation  of  section  through  vertebrate  body  to  show 
ontogenetic  relationship  of  the  various  orders  of  tissues.  A.  Of  lepidic  type:  1,  epiderm 
and  its  glands  (epiblastic) ;  2,  mucous  membrane  of  digestive  canal  and  its  glands,  liver, 
etc.  (hypoblastic) ;  3,  endothelium  lining  serous  cavities  (mesoblastic)  and  glands,  like 
renal  cortex,  of  mesothelial  origin;  4,  vascular  endothelium  of  late  mesoblastic  origin. 
B.  Of  hylic  type:  5,  spinal  cord,  brain,  and  nerves  (epiblastic);  6,  notochord  (hypo- 
blastic) ;  7,  connective  tissues  of  the  body  (mesenchymatous) ;  8,  myotomes,  striated 
muscle  of  body  (mesothelial).  C.  Cavities:  9,  lumen  of  digestive  tube;  10,  body  cavity. 
(Adami  and  McCrae.) 


Teratomas. — These  are  divided  by  Adami  into  two  main  classes, 
according  to  whether  the  teratoma  is  derived  from  the  same  indi- 
vidual as  the  person  possessing  the  tumor,  or  whether  it  is  derived 
from  a  twin  which,  becoming  atrophic  in  embryonal  or  early  fetal  life, 
remains  only  as  a  fetal  inclusion.  This  latter  class  produces  the 
various  forms  of  monsters,  chiefly  of  interest  to  obstetricians.  The 
former  class  comprises  those  tumors  usually  known  by  the  name 
teratoma.    These  tumors  may  spring  from  germinal  cells,  or  from  non- 


I  (Hi 


TUMORS 


germinal  cells;  in  the  former  instance  the  tumor  is  found  in  the  ovary 
(ovarian  "dermoid"),  where  a  large  cyst  is  usually  formed,  or  in  the 
testicle,  where  the  growth  (rare)  is  chiefly  solid,  with  only  a  small 
cyst;  while  in  the  latter  instance  the  most  frequent  site  is  at  one  end 
of  the  cerebrospinal  axis  (epignathus,  sacral  teratoma).  As  such 
tumors  spring  from  toti-potential  cells,  they  may  include  all  varieties 
of  tissues.  If  the  tumor  contains  elements  formed  from  all  three  of 
the  germinal  layers  it  is  known  as  an  embryoma.  Epithelial  struc- 
tures are  most  frequently  found,  especially  hair  and  teeth  (epiblast), 
or  glandular  tissue  (epi-  or  hypoblast) ;  occasionally  cartilage  or  bone 
(mesoblast). 

These  tumors  usually  are  present  at  birth  (Fig.  54),  but  frequently 
are  not  noticed  until  puberty.     Their  size,  shape,  and  consistency 

vary  according  to  their  location 
and  the  structures  composing  them. 
They  usually  grow  rapidly  when 
growth  once  begins,  and  may  become 
malignant,  giving  rise  to  metastases. 
They  are  best  treated  by  excision ;  but 
in  the  newborn  operation  should  be 
postponed  until  it  is  apparent  that  the 
child's  constitution  is  otherwise  suf- 
ficient to  support  life. 

Terato-blastomas. — These  tumors, 
derived  from  pluri-potential  cells, 
comprise  most  of  the  so-called 
"mixed  tumors" — tumors  in  which 
tissues  are  found  which  do  not  nor- 
mally exist  in  the  organ  or  tissue 
affected.  In  the  parotid,  and  sometimes  in  the  submaxillary  gland, 
cartilaginous  tumors  are  not  unusual;  in  the  kidney  such  tumors 
rarely  have  more  than  one  variety  of  aberrant  tissue,  and  have 
received  various  names  according  to  the  predominant  tissue — rhab- 
domyoma, adenosarcoma,  etc.  The  tumor  known  as  chorio-epithelioma 
{deciduoma  malignum)  belongs  to  this  group;  it  is  formed  by  neoplastic 
development  of  cells  of  the  chorionic  villi.  The  placental  mole  is 
believed  to  be  the  early  stage  of  such  development;  when  the  cells 
invade  the  uterine  sinuses  malignancy  is  evident  and  the  deciduoma 
is  present. 

The  terato-blastomas,  as  well  as  the  pure  embryomas,  often  exhibit 
malignant  characteristics,  and  are  best  treated  by  excision. 

Blastomas. — These  tumors,  forming  by  far  the  largest  group  of 
neoplasms,  result  from  the  independent  growth  of  uni-potential  cells. 
They  are  divided  by  Adami  into  two  main  groups,  according  as  they 
are  composed  chiefly  of  cells  arranged  like  epithelial,  or  rind,  tissues 
(Lepidic  tumors,  Lepidomas),  or  of  cells  arranged  like  the  stroma  or 
pulp  of  tissues  and  organs  {Hylic  Tumors,  Hylomas).  The  charac- 
teristic of  all  epithelial  structures  (skin,  mucous  membrane,  endo- 


Fig.  54. ; —  Sacro-coccygeal  tera- 
toma. Italian  girl,  aged  six  months. 
Pennsylvania  Hospital. 


XANTHOMA  107 

thelium)  is  that  the  cells  are  placed  closely  together,  there  being  an 
absence  of  definite  stroma  between  the  individual  cells,  and  no  blood- 
vessels penetrating  between  the  various  groups  of  cells.  The  char- 
acteristic of  all  pulp  tissues  (nervous  tissue,  muscle,  bone,  etc.)  is  that 
the  specific  cells  lie  in  and  are  separated  by  a  definite  stroma,  in 
which  blood  and  lymph  vessels  may  or  may  not  be  present.  Lepidic 
and  hylic  tumors  may  be  either  typical  or  atypical.  The  typical  blas- 
tomas  are  slow  growing,  and  their  structure  approaches  that  of  normal 
adult  tissue;  the  atypical  blastomas  are  composed  of  rather  immature 
cells,  do  not  closely  resemble  adult  tissue,  and  grow  rapidly.  Typical 
blastomas  are  more  or  less  encapsulated;  the  atypical  are  infiltrating. 
Typical  blastomas  are  benign,  atypical  blastomas  are  malignant. 

Examples  of  typical  (benign)  lepidic  tumors  are  papilloma,  adenoma; 
of  hylic  tumors,  are  fibroma,  osteoma.  Examples  of  atypical  (malig- 
nant) lepidic  tumors  are  epithelioma,  carcinoma;  of  atypical  hylic 
tumors  are  the  numerous  varieties  of  sarcoma. 

In  addition  to  distinct  tumors,  certain  blastomatoid  growths  (Adami) 
must  also  be  recognized;  they  approach  more  closely  the  reactive 
changes  of  inflammation,  and  correspond  to  the  "continuous  hyper- 
trophies" or  "out-growths"  of  Paget  (1853)  as  distinguished  from  the 
true  tumor  or  "  discontinuous  hypertrophy"  of  that  author. 

Typical  (Benign)  Hylic  Tumors. — The  most  important  of  these  are 
tumors  resembling  the  following  normal  tissues:  Fat  (Lipoma) ;  Fibrous 
Tissue  (Fibroma);  Cartilage  (Chondroma);  and  Bone  (Osteoma). 
Although  many  varieties  of  tissue  may  exist  in  the  same  tumor,  yet 
one  usually  is  so  predominant  as  to  give  its  name  to  the  growth. 
If  another  tissue  is  present  in  fairly  large  amount,  a  compound  term 
is  used,  thus  fibrolipoma,  the  tissue  present  in  greatest  abundance 
always  being  named  last. 

Lipoma. — This  may  consist  rather  in  an  hypertrophy  of  fat  normally 
present  (lipomatosis,  a  "continuous  hypertrophy  or  out- growth") 
than  in  an  actual  tumor.  Multiple  lipomas  are  not  rare.  A  lipoma 
rarely  is  well  encapsulated.  It  grows  slowly,  produces  no  discomfort 
except  from  its  size  or  position,  and  is  absolutely  benign.  The  skin 
over  it  is  not  discolored  nor  adherent,  though  a  slight  dimpling  may 
be  present  occasionally,  from  fibrous  bands  supporting  the  tumor 
between  the  skin  and  deep  fascia.  It  is  soft,  easily  movable  on 
the  underlying  tissues,  and  semi-fluctuating.  A  lipoma  sometimes 
will  gradually  shift  its  position  under  the  force  of  gravity.  It  may  occur 
on  any  part  of  the  body,  and  occasionally  in  the  sub-peritoneal  fat 
or  omentum.  Its  seats  of  predilection  are  the  limbs,  trunk,  and  neck 
(Fig.  55).  It  frequently  is  fibrous  in  character,  then  being  firmer 
than  a  pure  lipoma  (Fig.  56).  It  may  be  attached  by  a  pedicle  deep 
down  in  a  muscular  interspace,  occasionally  to  periosteum.  Mucoid 
degeneration  may  occur  (myxo-lipoma) ,  especially  in  internal  lipomas. 

Treatment.- — If  any  treatment  is  required,  excision  should  be  done. 

Xanthoma. — Xanthoma  is  a  small  flattened  benign  fatty  and  fibrous 
tumor  in  the  skin,  whose  nature  is  not  well  understood.     It  is  named 


108 


TUMORS 


from  its  yellow  color,  occurs  mosl  frequently  around  the  eyes,  and 
is  sometimes  seen  in  persons  with  gall-bladder  disease.  Usually  no 
treatment  is  required. 


gfak* 

P>  2S* 

-J^m 

J0 

flb  i 

Fig.  55. — Lipoma  of  neck,  duration 
nineteen  years.  Very  soft,  almost  fluctu- 
ating. (Not  goiter:  Dot  attached  to 
larynx;  does  not  lise  in  swallowing.) 
Episcopal  Hospital. 


Fig.  56. — Fibro-lipoma  of  right  cheek 
in  a  girl,  aged  fifteen  years;  growing 
slowly  for  last  nine  years.  Sight  of  left 
eye  lost  from  smallpox  in  infancy. 
Episcopal  Hospital. 


Fibroma. — Tumors  consisting  solely  of  fibrous  tissue  are  rare;  they 
usually  are  small  (Fig.  57),  frequently  multiple,  grow  slowly,  and  are  well 

encapsulated.  Depending 
upon  the  amount  of  fib- 
rous tissue  present,  fibro- 
mas  are  named  hard  or 
soft.  The  latter  is  the 
more  frequent  variety, 
and  is  well  represented 
by  the  mucous  polypi 
growing  in  the  naso- 
pharynx. The  tumor  is 
firm  to  the  touch,  pale 
and  glistening  on  section, 
with  a  capsule  usually 
demonstrable.  The  favor- 
ite sites  of  development 
are  the  subcutaneous  tis- 
sues, along  nerve  trunks, 
in  periosteum,  fascia,  the 
uterus  and  mammary 
gland.  Some  of  these 
must  be  regarded  as  fibroid  over-growths  rather  than  as  distinct  tumors, 
e.  g.,  fibroma  molluscum    (Fig.    58).     Fibromas   frequently    undergo 


Fig.  57. — Fibroma  pendulum.    Episcopal  Hospital. 


KELOID  OR  CHELOTD 


109 


degeneration,  particularly  the  mucoid,  forming  a  tumor  known  as 
myxoma;  this  is  especially  frequent  in  mucous  polyps;  a  tumor  in 
or  between  the  gluteal  muscles  usually  is  a  fibro-myxoma.  Malignant 
changes  are  by  no  means  rare,  the  cells  remaining  immature,  and 
proliferating  with  undue  activity,  forming  the  fibrosarcoma;  myxo- 
sarcoma also  occurs,  as  well  as  internal  hemorrhage  with  cyst  formation. 
Diagnosis. — Diagnosis  is  made  by  noting  the  long  duration;  indolent 
growth;  firm  consistence;  rounded,  apparently  encapsulated  character; 
and  normal  overlying  skin. 

^Treatment. — Frequently  none  is  required; 
but  any  suspicion  of  malignancy  (Fig.  -r)«)), 
aroused  by  rapid  growth,  apparent  myxo- 
matous or  cystic  changes,  etc., justifies  prompt 
extirpation.  Recurrence  is  not  very  rare, 
even  after  removal  of  an  apparently  benign 
tumor,  and,  as  a  rule,  the  recurrent  is  more 
malignant  than  the  primary  growth. 

Keloid  or  Cheloid.  —  The  hypertrophied 
condition  of  scars,  known  as  the  keloid  of 
Alibert  (1806), l  is  really  a  form  of  fibroma 


Fig.  58. — Neurofibroma- 
tosis (Fibroma  molluscuiii) . 
Aged  fifty-one  years.  Began 
at  fourteen  years.  Father 
had  the  same  condition. 
Episcopal  Hospital. 


Fig. 
eration. 


t. — Fibroma  of  back,  epitheliomatous    degen- 
Patient  aged  seventy-three    years;    duration 


fifteen  years.     Episcopal  Hospital. 


affecting  the  subepithelial  tissues.  It  almost  invariably  follows  some 
irritation,  though  individual  predisposition  has  much  to  do  with  its 
development.  Thus  it  is  often  seen  in  the  negro  race  (Fig.  60) ;  it 
may  develop  in  the  scars  of  burns,  or  of  comparatively  simple  opera- 
tions (Fig.  61).  There  is  some  evidence  that  it  is  of  tuberculous 
origin.  It  is  a  crab-like  (keloid)  or  scar-like  (cheloid)  out-growth, 
covered  by  red,  tense,  shiny  epithelium;  it  may  extend  into  sound 
tissues  in  various  directions.  It  usually  is  tender,  and  irritation  in- 
creases its  size.  Occasionally  the  out-growths  disappear  sponta- 
neously; they  usually  recur  after  excision. 

1  To  distinguish  it  from  the  Keloid  of  Addison  (1S54)  or  Morphoea,  an  affection 
belonging  rather  to  dermatology  than  surgery. 


110 


TUMORS 


Treatment. — Treatment  consists  in  protecting  them  from  irritation 
by  the  clothes  or  opposing  parts  of  the  body.    Ointments  of  tar  and 

zinc,  with  animal  rather  than 
mineral  bases,  are  valuable. 
Thiosinamin  (5  to  10  per  cent, 
solution)  hypodermically,  is 
recommended  by  Park  (1907). 
Chondroma. — A  tumor  com- 
posed chiefly  of  cartilage.  If 
it  springs  from  preexisting 
cartilage  cells  it  is  termed 
ecckondroma  (cartilaginous 
out-growth);  if  from  other 
forms  of  connective  tissue, 
especially  fibrous,  it  is  called 
enchondroma  (cartilaginous 
tumor).  Its  occurrence  as  a 
terato-blastoma  was  men- 
tioned at  p.  106.  Chondromas 
are  of  stony  hardness,  unless 
degenerated;  usually  more  or 
less  lobulated,  grow  slowly, 
but  usually  faster  than  lipomas 
or  fibromas,  the  growth  occur- 
ring chiefly  at  the  periphery; 
are  painless,  immovable,  fre- 
quently multiple ;  seldom  affect 
the  overlying  skin;  and  are  generally  quite  benign,  but  liable  to  form 
metastases.  They  are  especially  prone  to  mucoid  degeneration,  and 
when  such  occurs  malig- 
nancy should  be  suspected. 
Sarcomatous  changes  are 
not  unusual  (Fig.  529). 
True  bony  changes  (osteo- 
chondroma) sometimes  oc- 
cur. If  the  skin  sloughs,  the 
cystic  contents  of  the  de- 
generated chondroma  may 
discharge,  leaving  a  most 
intractable  sinus. 

Ecchondromas  arise  from 
epiphyseal  lines  before 
adult  life,  and  later  also 
from  articular,  costal,  and 
intervertebral  cartilages, 
larynx,  trachea,  etc.  En- 
chondromas  spring  from 
from  articular  cartilages. 


Fig.  60. — Keloid  (of  Alibert)  in  scars  toiiowmg 
a  whipping  from  patient's  mother.  Patient  of 
the  late  Dr.  Isaac  Massey,  of  West  Chester,  Pa. 


Fig.«61. — Keloid  in  scar  of  neck.  Had  brush  burn 
in  1907,  and  keloid  was  excised  one  month  later. 
Keloid  recurred,  and  present  photograph  made  one 
year  after  recurrence.     Episcopal  Hospital. 


periosteum    or    bone    marrow,    but    not 
Chondromas  develop  in  early  life,  espe- 


OSTOSES 


111 


cially  in  the  rachitic;  affect  especially  the  phalanges,  the  flat  bones 
(pelvis,  scapula,  skull),  the  femur,  and  the  maxilla.  When  growing 
on  the  surface  of  a  bone,  beneath  the  periosteum,  they  may  wear  away 
its  surface,  leaving  a  distinct  depression  when  they  are  removed. 

Diagnosis. — They  are  to  be  distinguished  from  bony  tumors  by 
their  occurrence  in  younger  patients,  by  their  situation,  and  by  their 
multiplicity;  but  a  differentiation  is  not  always  possible  without  the 
.r-rays.     Cartilage  casts  no  shadow,  or  at  most  a  very  light  one. 

Treatment. — Chondromas  should  be  completely  extirpated  when- 
ever possible.  Incomplete  removal  favors  recurrence,  and  the  recur- 
rences are  more  inclined  to  malignancy  than  the  primary  growths. 
Amputation,  except  of  the  phalanges,  is  rarely  required. 

Osteoma. — A  true  tumor  composed  solely  of  bone  is  decidedly  rare; 
most  so-called  bony  tumors  are  really  only  osseous  hypertrophies. 
True  osteoma  may  arise  on  the  surface 
of,  or  within  the  substance  of  bone.  In 
the  former  instance  it  grows  beneath 
the  periosteum;  in  the  latter  it  grows 
from  the  medulla,  being  then  known  as 
endosteoma.  Either  form  may  be  com- 
posed of  spongy  or  of  compact  bone. 
The  tumor  grows  by  cellular  proliferation 
of  its  own  elements,  not  from  partici- 
pation of  elements  in  the  surrounding 
bone;  these  latter  are  compressed,  pushed 
aside,  and  eventually  disappear  before 
the  ongrowing  tumor.  Thus  a  periosteal 
osteoma  will  excavate  the  underlying 
bone,  while  an  endosteoma  will  penetrate 
it,  break  through  the  cortical  bone,  and 
grow  more  freely  when  thus  relieved  from 
pressure.  Occasionally  an  osteoma  occurs 
in  tissue  which  normally  contains  no 
bone.  Such  a  tumor  is  a  heteroplastic 
osteoma;  it  is  possible  that  it  develops 
from  a  fetal  anlage,  but  usually  it  arises 

in  a  piece  of  cartilage  or  periosteum  which  has  been  displaced  by 
trauma  in  post-natal  existence.  That  true  bone  can  form  in  chon- 
dromas has  already  been  noted. 

Ostoses. — A  diffuse  bony  out-growth  is  called  a  hyperostosis;  a  cir- 
cumscribed, more  or  less  sessile  out-growth  is  an  exostosis;  a  projecting 
growth  with  narrow  base  is  an  osteophyte;  while  an  osseous  out-growth 
occurring  in  the  centre  of  a  bone  (e.g.,  arising  from  the  diploe)  is  termed 
an  endostosis  or  enostosis.  Occasionally  an  ostosis  of  one  form  or 
another  appears  to  become  neoplastic  in  nature,  exhibiting  autonomous 
proliferation.  Exostoses,  which  are  the  most  frequent  of  the  bony 
hyperplasias,  usually  are  multiple  (p.  485),  and  very  difficult  to  distin- 
guish from  multiple  ecchondromas,  especially  as  ossifying  changes  in  the 


Fig.  62. — Osteoma  of  upper 
jaw.  Four  years'  standing. 
From  a  patient  in  the  University 
Hospital  under  the  care  of  the 
late  Prof.  John  Ashhurst,  Jr. 


112  TUMORS 

latter  are  by  no  means  rare.  They  occur  in  the  same  situations  (except 
that  exostoses  are  very  rare  on  the  hands),  present  the  same  charac- 
teristics, and  run  the  same  clinical  course.  The  ivory  exostosis  of  the 
skull  is  an  exception,  which  it  is  usually  possible  to  distinguish 
clinically.  It  is  extremely  hard,  and  if  growing  from  the  diploe 
(enostosis)  may  be  as  prominent  on  the  dural  as  on  the  pericranial 
surface.  Ostoses  are  sometimes  developed  in  the  accessory  sinuses  of 
the  face.  Bony  changes  occurring  in  tendons,  muscles,  etc.,  arc  men- 
tioned at  p.  306. 

Diagnosis. — Diagnosis,  especially  of  endosteomas  and  enostoses, 
may  be  impossible  without  the  use  of  the  .T-rays,  by  which  the  denser 
shadow  of  osseous  growths  may  sometimes  be  distinguished  from  that 
cast  by  cartilaginous  tumors. 

Treatment.— Rarely  is  any  required,  unless  removal  of  one  or  more 
circumscribed  out-growths  is  necessary  to  relieve  pressure  on  nerves, 
bloodvessels,  the  brain,  etc.  Recurrence  after  thorough  extirpation 
is  exceptional. 

Odontoma. — The  teeth  are  developed  from  epiblast  and  mesoblast, 
and  while  a  tumor  having  its  origin  in  either  element  may  occur  in 
man,  the  vast  majority  of  odontomas  are  derived  from  the  epithelial 
portion,  and  are  seen  as  "cysts  lined  with  columnar  or  cuboidal 
epithelium  or  containing  gland-like  areas  in  their  wall"  (Simmons, 
1907).  This  form,  known  also  as  adamantinoma,  usually  springs  from 
the  lower  jaw,  the  tumor  growing  in  and  slowly  distending  the  body  of 
the  bone;  it  is  composed  of  multilocular  cysts,  with  a  bony  framework 
(multilocular  dentigerous  cyst).  It  occurs  especially  in  young  females, 
is  of  slow  growth,  and  usually  symptomless  except  when  causing  pres- 
sure on  neighboring  parts.  Crackling  may  be  detected  on  palpation 
if  the  growth  has  thinned  the  overlying  bone.  Usually  there  is  an 
unerupted  tooth  present. 

Diagnosis. — Diagnosis  sometimes  is  difficult,  especially  from  sar- 
coma. Carcinoma  is  more  frequent  on  the  upper  jaw  in  older  patients, 
and  ulceration  is  common.  Exostoses  and  chondromas  are  denser  and 
the  .r-rays  may  reveal  the  cystic  nature  of  the  adamantinoma.  Sarcoma 
in  this  situation  usually  is  periosteal  in  origin,  grows  rapidly,  quickly 
invades  the  soft  parts,  is  not  cystic,  and  presents  no  "egg-shell" 
crackling. 

Treatment. — Opening  the  growth,  and  destroying  its  interior  thor- 
oughly with  the  sharp  spoon  and  actual  cautery,  usually  effects  a  cure. 
It  is  essentially  benign.  The  operation  may  be  done  from  within  the 
mouth. 

Myeloma. — The  bone  marrow  contains  two  chief  varieties  of  cells — 
those  having  to  do  directly  with  bone,  and  those  supplying  the  blood. 
Adami  classes  under  this  section  tumors  derived  from  true  bone 
marrow  (osteogenetic)  cells,  and  certain  blastomatoid  conditions  due 
to  disturbances  of  the  blood  cell  elements  in  the  marrow. 

Giant-cell  Myeloma. — This,  frequently  spoken  of  as  giant-celled 
sarcoma,  is  too  little  malignant  to  be  classed  with  atypical  hylic 


MYELOMA 


113 


tumors.  It  may  develop  beneath  periosteum,  sometimes  occurs  in 
the  lower  jaw  or  clavicle,  but  usually  arises  in  the  interior  of  shafts 
of  long  bones,  near  the  epiphyses;  it  is  almost  the  only  tumor  found 
in  the  radius  (Figs.  63,  210  and  211);  it  occurs  in  the  young  (eighteen 
to  twenty-five  years),  frequently  (SO  per  cent,  of  cases)  follows  injury 
(or  the  patient's  attention  is  called  to  it  by  injury),  grows  slowly  and 
expands  the  overlying  bone  rather  abruptly.  The  bony  shell  may 
grow  so  thin  as  to  crackle  on  pressure  (spina  ventosa),  and  occasionally 
the  tumor  breaks  through  and  invades  the  soft  parts.  The  growth 
itself  is  rather  soft,  quite  vascular,  and  when  sectioned  resembles 
splenic  tissue  or  even  currant  jelly;  if  it  breaks  through  its  bony 
capsule,  pulsation  and  occasionally  bruit  are  present  (false  osteoid 
aneurysm,  p.  487).  Spontaneous  fracture  is  rare.  Skiagraphs  fre- 
quently show  evidences  of  trabeculation  (Fig.  210). 


Fig.  63. — Myeloma  (giant-cell  sarcoma)  of  radius,  duration  two  years;  developing  in  a 
girl,  aged  twenty  years,  from  no  recognized  cause.  Recurred  one  year  after  opening 
and  scraping.  Entire  lower  end  of  radius  then  excised,  and  bone  transplant  inserted. 
(See  Figs.  210  and  211.)  No  recurrence  and  useful  hand  five  years  later.  Episcopal 
Hospital. 

The  lymphatic  system  is  not  affected  in  pure  myeloma;  no  metas- 
tases occur;  and  if  the  tumor  is  thoroughly  removed,  recurrence  is 
unlikely.  Occasionally,  however,  the  tumor  approaches  spindle- 
celled  sarcoma  in  type,  the  stroma  cells  being  small,  growth  rapid, 
and  recurrence  usual. 

Diagnosis. — A  slowly  growing  tumor,  in  the  interior  of  a  bone,  and 
near  the  epiphysis,  if  in  a  long  bone,  occurring  before  twenty-five 
years  of  age,  not  producing  metastasis  or  cachexia,  expanding  the 
bone  abruptly,  and  appearing  trabeculated  in  skiagraphs,  is  usually 
a  giant-celled  myeloma.  The  diagnosis  from  fibro-cystic  osteitis 
and  bone  cysts  is  discussed  at  p.  487.  The  histological  diagnosis, 
according  to  Bloodgood,  who  has  studied  the  subject  periodically 
since  1903,  may  be  made  from  the  characteristics  of  the  stroma,  with- 
out regard  to  the  giant  cells;  the  stroma  resembles  granulation  tissue. 
Barrie  (1913)  goes  further,  and  claims  that  it  actually  is  granulation 
tissue;  he  terms  the  disease  hemorrhagic  osteomyelitis  and  considers 
it  a  stage  precedent  to  fibrocystic  osteomyelitis.  He  contends  that 
it  is  traumatic  in  origin,  results  from  rupture  of  osseous  trabecula? 
near  the  medullary  cavity,  that  spontaneous  rupture  of  the  thin-walled 
bloodvessels  ensues  from  lack  of  bony  support,  and  that  the  granu- 
lation tissue  is  an  ineffectual  effort  to  repair  the  damage.  From  long- 
8 


114  TUMORS 

continued  low-grade  irritation,  here,  as  elsewhere  in  the  body,  he 
thinks  this  granulation  tissue  continues  to  proliferate  and  gradually 
expands  the  cortex.  M.  J.  Stewart  (1914),  on  the  other  hand,  who 
studied  55  giant-celled  tumors  arising  in  bone,  based  his  pathological 
diagnosis  on  the  character  of  the  giant  cells  which  in  the  benign  growths 
(50  out  of  the  total  ')')  studied)  resemble  osteoclasts:  their  cytoplasm 
is  abundant  and  vacuolated;  the  nuclei  (small  and  very  abundant) 
are  collected  in  the  center  of  the  cell  and  arranged  in  whorls;  and 
there  are  no  mitoses  within  the  giant  cells.  (Stewart's  views  on  the 
malignant  giant-celled  sarcoma  are  mentioned  at  p.  119).  It  may 
be  remarked,  in  regard  to  Barrie's  views,  that  the  giant  cells  form 
too  prominent  a  feature  of  the  histological  picture  to  he  relegated 
to  the  role  of  foreign  body  giant  cells;  the  latter  normally  are  col- 
lected around  the  periphery  of  the  lesion  which  they  are  seeking  to 
remove,  and  their  histological  structure  is  not  such  as  is  commonly 
seen  in  cases  of  myeloma.  Clinically,  at  any  rate,  the  myeloma  is  a 
tumor  though  a, 'benign  one. 

Treatment. — Usually  it  is  sufficient  to  cut  away  the  overlying  bone 
and  clean  out  the  interior;  cauterization  probably  is  of  little  value 
if  the  cavity  is  thoroughly  scraped.  If  the  cavity  is  small  it  may  be 
allowed  to  fill  with  blood,  its  walls  being  crushed  in;  or  it  may  be 
plugged  with  iodoform  bone-wax  (p.  478),  the  soft  parts  being  com- 
pletely closed.  If  the  growrth  is  very  large  and  vascular,  the  opera- 
tion may  be  done  under  Esmarch  anemia  (p.  476),  and  the  cavity 
packed  for  several  days  with  gauze,  when  secondary  closure  may  be 
done.  Only  in  cases  very  far  advanced,  or  recurrent  after  incomplete 
operation  (Fig.  63)  is  formal  resection  of  the  bone  necessary.  Ampu- 
tation is  reserved  for  the  aged  or  feeble,  or  those  cases  in  which  the 
disease  is  believed  to  be  malignant. 

Myelomatosis. — This  blastomatoid  condition  affects  the  red  bone 
marrow  chiefly  of  the  vertebras,  ribs,  pelvis,  and  cranium;  it  is  a  primary 
multiple  process  (Borst).  The  growths  are  yellowish  red,  pulpy,  and 
firm,  and  though  it  is  due  (Adami)  to  proliferation  of  the  blood-forming 
elements  of  the  marrow,  there  is  in  orthodox  cases  no  involvement 
of  the  lymphatic  system  or  spleen  (such  a  condition  being  called 
myelogenous  leukemia).  Albumosuria  (Bence-Jones,  1848)  is  frequent 
in  myelomatosis,  and  relations  of  this  disease  to  osteomalacia  are  not 
clear.  Prognosis  is  bad,  death  from  exhaustion  occurring  after  an 
interval  of  months  or  years.  Treatment  is  sometimes  required  because 
out-growths  in  the  vertebra?  press  on  the  cord;  excision  or  laminectomy 
should  be  done. 

Chloroma. — Chloroma,  according  to  Adami,  is  an  aberrant  type  of 
myelomatosis;  it  is  a  rather  malignant,  multiple  growth  of  greenish- 
yellow  tint,  affecting  especially  the  face  bones;  and  is  frequently 
associated  with  myeloblasts  leukemia  (Dock). 

Lymphomatosis. — As  myelomatosis  is  due  to  proliferation  of  blood- 
forming  marrow  cells  (myeloblasts,  which  produce  leukocytes),  so 
lymphomatosis  is  a  corresponding  state  due  to  hyperplasia  of  lympho- 


ATYPICAL  HYLIC   TUMORS  115 

blasts.  There  are  many  affections  characterized  by  widespread 
enlargement  of  lymphatic  tissue,  notably  tuberculosis;  there  are  others, 
probably,  but  not  certainly  tuberculous;  and  there  is  Hodgkin's 
disease,  of  unknown  cause  (p.  302);  leukemia  is  still  another,  but  has 
no  surgical  interest.  Adami,  in  addition  to  the  above  blastomatoid 
conditions,  admits  the  existence  of  typical  lymphoma;  but  far  more 
frequent  is  atypical  lymphoma,  comprising  the  various  forms  of  lympho- 
sarcoma (p.  304). 

Myoma. — The  leiomyoma  is  a  tumor  composed  of  smooth  muscle 
fibers,  arranged  in  various  directions,  and  inclosed  in  a  fibrous  stroma 
(fibromyoma).  The  older  the  tumor  the  more  does  fibrous  tissue 
preponderate,  so  that  finally  muscular  fibers  may  be  inconspicuous 
(fibroids) ;  this  change  may  be  a  mere  over-growth  of  fibrous  tissue,  or 
an  actual  metaplasia  of  muscle  fibers  (Adami).  It  occurs  with  over- 
whelming frequency  in  the  uterus  (Chapter  XXIX),  but  occasionally 
is  found  in  other  portions  of  the  genito-urinary  system  or  in  the  diges- 
tive tract,  where  the  stomach  is  most  often  affected.  The  tumors  are 
usually  multiple,  may  attain  immense  size,  and  frequently  require 
excision. 

Rhabdomyoma. — The  occurrence  of  this  tumor,  except  in  connec- 
tion with  terato^blastomas  (p.  106),  is  almost  unknown.  It  appears 
usually  to  be  malignant. 

Neuroma. — A  true  ganglionar-celled  neuroma  is  so  rare  as  to  be  of 
slight  interest  surgically,  except  when  it  occurs  in  the  medulla  of 
the  adrenal  (p.  1038).  False  neuromas  are  fibrous  "out-growths" 
occurring  upon  nerves  (fibromatosis  nervorum).  Amputation  neuromas 
are  somewhat  similar  (p.  221). 

Glioma. — This  is  a  tumor  developed  from  the  stroma  of  nerve 
tissue  (neuroglia)  (Fig.  64);  it  is  found,  with  few  exceptions  (retina, 
cerebral  nerves),  in  the  brain;  and  may  be  either  hard  (when  pro- 
jecting into  the  ventricles);  or  soft,  when  it  infiltrates  the  cerebral 
hemisphere  without  any  attempt  at  encapsulation  (p.  627). 

Chordoma. — Chordoma  is  a  rare  tumor  growing  from  bone  in  the  region 
of  the  pituitary  bod}',  and  developed  from  remains  of  the  notochord. 

Atypical  (Malignant)  Hylic  Tumors. — Sarcoma. — The  characteristics 
of  malignancy  in  general  (p.  102)  and  of  atypical  blastomas  in  par- 
ticular (p.  107)  have  already  been  considered.  Sarcomas  are  atypical 
hylomas  of  mesenchymal  origin,  all  possessing  this  peculiarity,  that 
they  are  composed  of  embryonic  connective  tissue  cells.  Sarcoma 
may,  therefore,  occur  wherever  connective  tissue  exists;  indeed,  as 
pointed  out  by  Bland-Sutton  (1906),  it  may  be  regarded  as  a  malig- 
nant tumor  disease  of  connective  tissue.  Sarcoma  occurs  by  prefer- 
ence, however,  in  bone,  periosteum,  fascia,  ligaments,  tendons,  brain, 
ovaries,  testicles,  and  skin;  less  often  in  the  lungs,  muscles,  uterus, 
liver,  and  intestines.  It  grows  rapidly,  by  cellular  proliferation  in  all 
parts  of  the  tumor,  frequently  assumes  a  lobular  appearance,  infiltrates 
in  all  directions,  particularly  along  and  inside  of  bloodvessels,  and 
early  gives  rise  to  metastasis  through  the  blood-stream.      Though 


116  TUMORS 

most  sarcomas  infiltrate  equally  in  all  directions,  certain  tumors  extend 
in  finger-like  processes  here  and  there,  giving  an  organoid  appearance 
to  the  section.  Such  growths  have  been  termed  alveolar  and  tubidar 
sarcomas.  A  special  characteristic  of  all  sarcomas  is  the  extreme 
meagrcness  of  the  stroma  present;  only  with  difficulty  may  stroma 
he  detected,  so  closely  are  the  sarcoma  cells  packed  together.  Sar- 
comas are  highly  vascular,  and  the  walls  of  the  bloodvessels  are  com- 
posed solely  of  endothelial  cells;  the  sarcoma  cells  lie  in  immediate 
contact  with  the  outer  surface  of  the  endothelium,  and  frequently 
grow  inside  the  vessels.  A  characteristic  of  rapid  growth  and  of 
the  vascularity  of  these  tumors  is  their  liability  to  myxomatous  and 
other  degenerations,  to  internal  hemorrhages,  and  to  cyst  formation 
(p.  103). 


NSW 


Fig.  64. — A,  from  the  more  typical  portion  of  a  glioma.    B.  Another  region  from  same 
growth  of  more  malignant  type,  a  true  gliosarcoma.     (Thomas  and  Hamilton.) 

Sarcomas  are  classified  according  to  the  form  and  size  of  their 
component  cells  into  small  round-celled,  large  round-celled,  and  spindle- 
celled  sarcomas  (Figs.  65  and  66) ;  or,  where  several  kinds  coexist, 
mixed-celled  sarcomas.1  The  smaller  the  cell  and  the  less  the  amount 
of  stroma,  the  more  malignant  is  the  sarcoma;  therefore,  the  large 
spindle-celled  sarcoma  (formerly  called   "recurrent  fibroid")  is  the 

1  M.  J.  Stewart  (1914)  as  already  noted  (p.  114)  recognizes  a  malignant  giant- 
celled  sarcoma,  five  specimens  of  which  he  studied;  all  the  patients  died  within 
three  years  of  the  time  of  operation.  He  bases  the  diagnosis  on  the  following 
microscopical  appearances:  The  giant  cells  are  of  all  sizes,  and  one  may  detect 
all  stages  of  transition  from  ordinary  tumor  cells  up  to  typical  giant  cells;  mitoses 
are  very  frequent  both  in  the  giant  cells  and  in  the  cells  of  the  stroma,  and  the 
nuclei  of  the  former  are  exceedingly  irregular  in  size  and  shape,  most  of  them 
being  large,  and  seldom  more  than  six  being  present  in  one  cell.  Vacuolation  of 
the  cytoplasm  is  rare.     These  features  serve  to  distinguish  it.  from  the  myeloma. 


SARCOMA 


n: 


least  malignant,  probably  because  in  the  others  the  cells  are  less 
developed,  the  most  so  in  this.  The  form  of  the  sarcoma  cell 
depends  on  the  structure  from  which  it  is  derived;  thus,  as  pointed 
out  by  Adami,  only  cells  which,  in  the  course  of  their  normal  develop- 
ment, pass  through  a  spindle-celled  stage  can  give  rise  to  spindle- 
celled  sarcoma  (connective  tissue  cells,  plain  muscle  fibers,  etc.); 
whereas  round-celled  sarcomas  are  developed  from  cells  such  as 
lymphocytes,  which  even  when  normally  matured  are  still  round. 
Finally,  calling  the  above  pure  sarcomas,  a  group  of  intermediate 
sarcomas  may  be  recognized,  in  which  some  of  the  cells  develop  beyond 
the  embryonal  stage  sufficiently  to  give  a  tissue  characteristic  to  the 
tumor,  but  do  not  reach  full  adult  maturity:  fibrosarcoma,  lympho- 
sarcoma, osteosarcoma,  chondrosarcoma,  gliosarcoma,  etc. 


Fig.  65. — Small  round-celled  sarcoma 
from  skin.  (High  magnification.)  (From 
Professor  Klotz.) 


Fig.  66. — Spindle-celled  sarcoma  (recur- 
rent, from  forearm) :  a,  delicate-walled 
bloodvessel  in  tumor.  (From  Professor 
Klotz.) 


It  is  an  interesting  question,  as  yet  undecided  by  pathologists, 
whether  the  term  sarcoma  shall  be  applied  to  a  tumor  composed  of 
any  cells  other  than  connective  tissue  cells.  Thus,  if,  for  example,  a 
sarcomatous  tumor  is  found  in  (smooth)  muscle  tissue,  it  may  have 
originated  (1)  by  sarcomatous  proliferation  of  the  connective  tissue 
cells  (not  muscle  cells)  in  the  tissue  of  a  normal  muscle  or  of  a  typical 
leiomyoma  (p.  115);  (2)  by  malignant  proliferation  ab  initio  of  the 
muscle  cells  themselves;  or  (3)  by  a  secondary  sarcomatous  change 
(anaplasia)  affecting  the  muscle  cells  in  a  previously  formed  myoma. 
To  the  first  tumor  the  name  myosarcoma  is  properly  applied;  the 
second,  which  many  hold  is  not  truly  a  sarcoma,  is  best  described  as 
a  malignant  myoma;  while  the  third  is  distinguishable  from  the  others 
by  the  term  myoma  sarcomatodes.  According  to  Adami,  this  last  is 
probably  the  most  frequent  form;  but  most  pathologists,  I  believe, 
still  regard  the  first  as  the  most  usual.  The  same  question  arises  in 
connection  with  glioma,  lymphoma,  endothelioma,  etc.,  and  also  with 


118 


Tf  .units 


osteosarcomaj  fibrosarcoma,  etc.,  though  not  so  pointedly  in  these 
hitter,  because  they  are  formed  of  connective  tissue  alone. 


Fig.   67. — Inoperable  sarcoma  of  pelvis;  rapid   growth  after  exploratory  laparotomy 
six  months  ago.     Note  ecchymosis  of  hip  from  recent  bruise.     Children's  Hospital. 

Diagnosis. — Sarcoma  occurs  usually  in  the  young  (over  forty  years 
it  is  quite  rare),  not  infrequently  follows  trauma,  grows  rapidly 
(weeks  and  months),  causes  early  metastasis, 
especially  in  the  lungs  and  skin;  is  frequently 
hot  and  painful;  and  eventually  produces 
cachexia.  It  is  firm  but  not  bony  to  the 
gm  touch    if   growing    from    bone    or   cartilage; 

ffl  rather  soft  if  in  fibrous  tissue  or  the  viscera. 

m  £  Prognosis. — This  is  gloomy.     Recurrences 

are  almost  inevitable;  and  even  if  no  recur- 
Jk  rence  occurs  locally,  visceral  metastases,  un- 

detected at  time  of  operation,  almost  surely 
H  kill   within   two  or  three  years. 

wk  Treatment.  —  Prompt    extirpation,    which 

often  but  not  always  implies  amputation 
of  the  limbs,  and  wide  cutting  excision  of 
other  parts,  offers  the  only  chance  of  cure. 
Reoperation  for  local  recurrences  sometimes 
prolongs  life,  though  rarely  effecting  a  cure. 
■tag  ^n|        If  *ne  tumor  is   inoperable  when  first  seen, 

(i_.^  treatment  with  Coley's  fluid  should  be  tried; 

and  in  all  cases  it  should  be  used  after 
operation.  The  mixed  toxins  of  the  B.  pro- 
digiosus  and  streptococcus,  introduced  by 
Coley  of  New  York  in  1892,  are  administered 
hypodermically,  either  into  the  growth  itself 
or  its  immediate  neighborhood  (initial  dose 
\  to  |  a  minim),  or  in  other  parts  of  the  body 
(initial  dose  1  minim),  the  dose  gradually 
being  increased  so  that  it  is  no  more  than 
sufficient  to  cause  febrile  reaction  analogous  to  that  seen  with  tuber- 
culin  (p.  79).     It   has   been  a  clinical  observation  for  nearly  fifty 


Fig.  68.  —  Spindle-cell 
sarcoma  of  the  leg.  Aged 
forty-four  years.  Direct 
injury  November,  1914. 
Tumor  noticed  March, 
1915.  Photograph  and 
operation,  September  1, 
1915.  Coley's  fluid  for 
many  months.  No  recur- 
rence four  years  later. 
Episcopal  Hospital. 


PAPILLOMA 


119 


years  that  attacks  of  erysipelas  occasionally  had  a  healing  influence 
on  malignant  growths;  and  it  is  not  an  illogical  theory  that  bacterial 
toxins  might  influence  tumor  cells  favorably,  reducing  the  process 
more  nearly  to  that  of  an  inflammatory  reaction.  As  a  matter  of 
fact,  the  use  of  Coley's  fluid,  especially  in  his  own  hands,  has  secured 
some  surprisingly  favorable  results:  in  a  few  instances  permanent 
cure  has  followed;  in  many  the  tumors  have  been  reduced  to  operable 
states,  or  have  been  kept  in  abeyance,  as  it  were,  for  sometimes  they 
grow  again  when  treatment  is  discontinued;  in  some,  recurrence 
seems  to  have  been  prevented.  My  own  experience  with  Coley's 
fluid  has  been  limited,  but  on  the  whole  favorable;  the  tumor  has 
at  least  grown  smaller,  and  the  pain  and  discomfort  of  the  patient 
have  been  noticeablv  relieved. 


Fig.  69. — .Specimen  removed  from  patient  shown  in  Fig.  68,  viewed  from  median 
aspect.  Specimen  includes  entire  thickness  of  tibia  with  articular  surface  of  knee. 
See  Figs.  212  and  213. 

Typical  (Benign)  Lepidic  Tumors. — Papilloma. — This  is  an  epithelial 
tumor  growing  from  skin  or  mucous  membrane  (Fig.  51).  It  projects 
above  the  surface,  sometimes  as  a  single  nodular  mass,  sometimes  as  a 
definitely  papillomatous  out-growth.  Its  nourishment  is  derived  from 
vessels  which  are  carried  to  it  in  a  core  of  the  underlying  connective 
tissue;  but  the  connective  tissue  itself  typically  undergoes  no 
blastomatous  change,  merely  growing  as  required  by  the  inde- 
pendent growth  of  overlying  epithelium.  Most  so-called  papillomas 
(warts,  etc.,  p.  290)  are  clearly  not  neoplasms,  but  hyperplasias  due 
to  chronic  irritation.  Some  of  the  mucous  polypi  described  as  soft 
fibromas  (p.  108)  may  be  considered  as  forms  of  papilloma,  if  it  is  the 
epithelium  and  not  the  connective  tissue  core  which  becomes  blasto- 
matous; the  question  is  very  hard  to  decide.  True  papillomas  occur 
chiefly  on  mucous  surfaces,  especially  the  urinary  bladder,  where  the 
tumor  is  composed  of  numerous  fine  finger-like  projections  (Fig. 
70);  stomach  (polyposis);  rectum;  uterus,  etc.  Similar  tumors  often 
grow  from  the  mucous  lining  of  cysts,  especially  in  cystic  adenomas 
(intracystic  papillomas)  (Fig.  71). 

Treatment. — -As  malignant  changes  (carcinoma)  are  not  very  un- 
common, papillomas  are  best  treated  by  excision;  and,  unless  this  is 
thorough,  recurrence  is  frequent,  especially  in  the  bladder. 


120 


TUMORS 


Adenoma. — Instead  of  the  lining  membrane  presenting  outgrowths, 
as  in  the  case  of  papilloma,  ingrowths  may  occur;  as  this  change  is 
almost  limited  to  preformed  glands,  the  resulting  neoplasm  is  called 
an  adenoma.  It  is  not  a  very  common  tumor,  being  encountered 
most  often  in  the  mamma,  thyroid,  liver,  prostate,  and  around  the 
margins  of  gastric  ulcers.  In  the  two  latter  situations  it  is  probable 
that  the  change  is  one  of  adenomatosis,  a  hyperplastic  reaction  to 
chronic  irritation.  The  more  important  adenomas  are  discussed  in 
connection  with  transitional  lepidomas  (p.  128).  The  true  adenoma 
probably  always  originates  in  cell  rests;  it  is  well  encapsulated,  and 
has  no  communication  through  ducts  with  the  excretory  channels  of 
the  gland  in  which  it  lies.  The  cells  forming  an  adenoma  usually 
retain   some  of  their  glandular  characteristics,   and    may   secrete  a 


Fig.  70. — Papilloma  of  bladder  to 
show  the  long' finger-like  papillomatous 
outgrowths.     (Ribbert.) 


Fit;.  71 


-Intracystic  papilloma  of  breast. 
(Orth.) 


modified  form  of  the  natural  product;  this  secretion  then  distends  the 
acini,  and  a  cystadenoma  is  produced.  Into  these  cysts  papillomatous 
growths  frequently  occur  (Fig.  71),  producing  intracystic  papilloma, 
or  cystadenoma  papilliferum.  Here  again  it  is  exceedingly  difficult 
to  tell  whether  the  projections  are  truly  papillomatous  or  whether 
they  are  only  apparently  papillomatous,  being  caused  by  the  adjacent 
in-growth  of  adenomatous  cells.  In  many  adenomas  the  fibrous  stroma 
is  markedly  increased  {fibroadenoma),  and  it  is  held  by  some  that 
neoplastic  proliferation  of  this  stroma  is  the  cause  of  the  papilloma- 
tous intracystic  projections,  and  that  the  epithelium  overlying  the 
projections  is  entirely  passive.  The  cells  of  an  adenoma  always  lie 
upon  a  well  developed  basement  membrane,  which  invariably  sepa- 
rates them  from  the  underlying  stroma ;  when  the  tumor  grows  rapidly 
this  basement  membrane  may  be  poorly  developed;  and  when  it  is 


CARCINOMA  121 

absent,  and  the  epithelial  cells  have  broken  through,  lying  in  immediate 
contact  with  the  stroma,  the  tumor  can  no  longer  be  considered  an 
adenoma:  it  has  undergone  malignant  (carcinomatous)  change.  Bland- 
Sutton  (1917)  denies  that  such  a  change  ever  occurs.  An  adenoma 
may  be  very  small,  or  extremely  large  and  ponderous;  the  smaller, 
harder,  tumors  of  the  breast  are  usually  painful. 

Treatment. — Adenomas  should  be  removed  whenever  possible;  espe- 
cially does  rapid  growth  render  this  imperative.  Recurrence  is  not  to 
be  feared;  and  metastasis  is  unknown. 

Atypical  (Malignant)  Lepidic  Tumors. — Carcinoma. — This  includes 
all  malignant  tumors  of  epiblastic  or  hypoblastic  origin.  Under 
carcinoma  of  epiblastic  origin  are  included  all  skin  cancers,  as  well  as 
cancers  derived  from  the  mammary  and  other  epidermal  glands, 
epithelium  of  mouth,  salivary  glands,  naso-pharynx,  etc.;  while  those 
of  hypoblastic  origin  include  carcinoma  of  the  digestive  tract,  pancreas, 
liver,  bladder,  and  respiratory  tract,  thyroid,  thymus,  tonsils,  etc. 
Although  the  cause  of  carcinoma  is  totally  unknown,  most  cases  occur 
in  persons  over  forty  years  of  age,  and  it  is  most  frequent  in  sites 
which  have  long  been  subjected  to  irritation,  or  in  which  unhealed 
and  chronically  irritated  ulcers  exist — e.  g.,  lacerations  of  the  cervix 
uteri,  gastric  ulcer,  smokers'  cancer  of  the  lower  lip,  syphilitic  ulcers 
of  the  tongue,  chimney-sweep's  (soot)  cancer  of  the  scrotum,  cancer  of 
the  skin  in  workers  in  paraffin,  pitch,  chrome,  etc. 

Carcinoma  is  due  to  the  independent  (autonomous)  growth  of  epi- 
thelial cells;  and  this  growth  is  atypical.  That  is  to  say,  it  differs  not 
only  from  the  growth  of  epithelial  cells  seen  in  regeneration  (healing 
of  ulcers),  but  it  also  differs  from  the  growth  of  epithelial  cells  seen  in 
an  adenoma.  In  an  adenoma,  for  instance,  the  epithelial  cells  retain 
to  a  certain  degree  their  normal  character;  they  line  the  gland  tubules 
or  acini,  leaving  usually  a  distinct  lumen,  and  rarely  forming  more 
than  one  layer  around  this  central  lumen;  and  they  are  always  placed 
on  a  distinct  basement  membrane.  In  carcinoma,  on  the  other  hand, 
the  in-growths  of  epithelial  cells  are  usually  solid,  finger-like  masses; 
there  is  no  lumen,  except  in  certain  cancers  derived  from  preformed 
glands,  and  even  then  the  cells  tend  to  pile  upon  each  other  around 
the  periphery  and  to  encroach  on  the  lumen;  the  basement  mem- 
brane is  absent,  and  the  masses  of  epithelial  cells  are  in  direct  contact 
with  the  surrounding  tissues.  When  seen  in  cross-section  it  appears 
as  if  there  were  cell  nests  entirely  detached,  lying  in  the  connective 
tissues;  but  rarely,  if  ever,  is  this  the  case.  It  has  been  shown  by  serial 
sections  (Petersen)  that  these  are  directly  continuous  with  the  sur- 
face epithelium,  being  one  of  the  claws  of  the  crab-like  growth  which 
gives  cancer   its   name. 

Not  only  does  carcinoma  extend  in  all  directions  into  all  surround- 
ing tissues,  but  it  has  a  very  extraordinary  tendency  to  extend  along 
lymphatic  channels.  It  was  formerly  thought  that  this  extension  was 
largely  in  the  way  of  metastasis,  i.  e.,  that  groups  of  carcinoma  cells 
were  detached  from  the  main  tumor  and  carried  in  the  lymph  current 


122 


TUMORS 


away  from  their  site  of  origin,  until,  lodged  in  the  nearest  lymph  nodes, 
they  there  set  up  a  metastatic  growth  entirely  separate  from  the  main 
tumor,  leaving  uninvolved  tissue  between.  Thai  this  sometimes  occurs 
may  not  be  denied,  but  it  is  certain,  owing  chiefly  to  the  researches 
of  Handley  (1905)  in  relation  to  mammary  carcinoma,  that  in  the 
vast  majority  of  cases  such  extension  occurs  by  direct,  continuity 
(permeation)  along  the  lymphatic  spaces  of  the  deep  fascia,  and  along 
lymph  vessels,  and  that  the  affected  lymph  nodes  are  connected  with 
the  primary  tumor  by  innumerable  fine  cords  of  carcinoma  celts.  When 
the  lymph  nodes  are  invaded,  dissemination  beyond  them  may  occur, 
the  carcinoma  cells  eventually  entering  the  blood-stream  and  being 


::'-.m 


i^fa 


?■*•;?,- 


- 


g  v. 


If 

•■•  *         »v£  ©J*2  - 
■ 


....       .' 


Fig.  72. — Early  epithelioma  of  tongue,  to  show  (a)  region  of  origin  by  down-growth 
from  preexisting  epithelium;  b  b,  epithelial  pearls;  c,  small-celled  infiltration  in  sur- 
rounding tissue.     (Petersen.) 

widely  disseminated  in  the  lungs,  spine,  etc.  Occasionally,  dissemina- 
tion by  the  blood  occurs  early,  before  the  adjacent  lymph  nodes  are 
palpably  affected.  These  secondary  growths,  wherever  found,  repro- 
duce the  character  of  the  primary  tumor;  we  may  find  in  the  humerus 
a  secondary  nodule  with  the  characteristics  of  the  glands  of  the  rectum, 
nodules  in  the  ovary  with  the  features  of  the  mammary  gland,  etc. 
Secondary  deposits  are  rarest  in  muscle,  most  frequent  in  the  skin, 
lungs,  and  bone,  especially  the  vertebrae,  as  well  as  in  organs  anatomic- 
ally related  to  the  primary  growth. 

Two  main  varieties  of  carcinoma  may  be  recognized:  Epithelioma 
and  Glandular  Carcinoma. 


EPITHELIOMA 


123 


Epithelioma. — Though  this  term  is  applied  by  the  French  to  all 
malignant  tumors  of  epithelial  origin,  it  is  customary  among  English 
speaking  surgeons  to  limit  it  to  squamous-celled  carcinoma,  and  it  is 
so  used  in  this  volume.  It  affects  the  skin,  especially  muco-cutaneous 
junctures  (lips,  anus,  glans  penis,  vulva),  mouth,  tongue,  pharynx, 
esophagus,  etc.  Very  exceptionally  epithelioma  has  been  found  where 
no  squamous  epithelium  normally  exists  (gall-bladder,  stomach, 
uterus,  etc.).  Pre-cancerous  changes  are  well  recognized  clinically. 
Among  those  of  most  importance  are  the  senile  or  seborrheic  patch 
(keratosis,  p.  6G9);  leukoplakia  (p.  695);  and  Paget' s  disease  (p.  768). 
As  already  noted,  any  chronic  irritation  seems  to  predispose  to  the 
development  of  carcinoma. 

Two  forms  of  epithelioma  are  distinguishable,  the  superficial,  and 
the  deep-seated,  of  which  the  last  will  be  described  first. 

1.  Deep-seated  Epithelioma. — This,  the  more  frequent  variety, 
commences  as  a  downward  proliferation  of  epithelial  cells  which 
preserve  fairly  well  the  typical  appearance  of  cells  of  the  rete 
Malpighii,  a  few  "prickle"  cells  frequently  being  discernible.  These 
cells  are  very  slightly  anaplastic:  they  preserve  their  functions  so  far 
that  they  still  tend  to  undergo  horny  changes,  this  keratosis  resulting 
in  the  formation  of  "pearly 
bodies,"  which  are  really  cross- 
sections  of  plugs  in  which  the 
central  cells  have  become  horny, 
and,  being  compressed  by  those 
outside,  produce  a  typical  lami- 
nated appearance  (Fig.  72).  A 
little  round-celled  infiltration 
may  be  seen  around  these  in- 
growths, evidences  of  reaction 
on  the  part  of  the  stroma. 

This  form  of  epithelioma  when 
growing  on  the  skin  usually  is 
first  noticed  by  the  patient  as 
an  induration  (hyper-keratosis), 
commencing  frequently  in  a 
senile  seborrheic  patch  (p.  699) . 
Or  it  may  develop  from  a  papil- 
loma (Fig.  73).  Soon  the  center 
becomes  abraded,  crusts,  ulcer- 
ates, and  gives  the  growth  an 
umbilicated  appearance  (Fig. 
74).  This  ulcer  spreads;  its 
edges  may  retain  the  features  of 
the  original  nodule,  but  usually  are  less  firm,  ragged,  and  only  moder- 
ately raised  above  the  base  of  the  ulcer.  It  occurs  especially  on  the 
face  and  hands,  the  lower  lip  being  a  favorite  site.  The  neighboring 
lymph  nodes  are  invaded  early  (three  to  five  months),  and  the  progress 


Fig.  73. — Epithelioma  of  nose;  aged  sixty- 
three  years;  duration  one  year.  (Developing 
in  a  papilloma.)      Episcopal  Hospital. 


[24 


TUMORS 


Fig.  74. — Epithelioma  of  hand ;  aged  seventy- 
eight  years;  duration  one  year.  Note  uni- 
bilicated  appearance.     Episcopal  Hospital. 


of  the  disease  is  imieli  more  raj>i<l  than  thai  form  about  to  be  <le- 
scribed.  The  stench  from  these  ulcerated  surfaces  is  sometimes  frightful, 
and  alarming  hemorrhages  may  occur  in  the  later  stages.  Occasion- 
ally, early  in  the  course  of  the  disease,  the  ulcer  is  covered  with  warty 

excrescences  (Papillary  Epi- 
thelioma) (Fig.  75),  forming 
one  variety  of  Marjolin's  ulcer 
(p.  57) ;  but  these  warty  granu- 
lations often  disappear  as 
ulceration  progresses. 

Diagnosis. — This  will  be 
considered  more  in  detail  in 
the  chapters  devoted  to  re- 
gional surgery.  Any  chronic 
ulcer  of  the  skin  or  adjacent 
mucous  membranes  should  be 
regarded  with  suspicion.  Epi- 
thelioma in  leg  ulcers,  though 
very  unusual,  is  sometimes 
seen;  it  is  less  infrequent  in 
the  heel. 
Prognosis  is  good  if  excision  is  done  early,  before  lymph  nodes  are 
palpably  enlarged;  later,  recurrence  is  frequent. 

Treatment. — Early  excision,  in  one  mass  with  the  adjacent  lymph 
nodes  and  all  intervening  subcutaneous  tissue,  is  the  only  form  of 
treatment  which  offers  hope  of  perman- 
ent cure.  If  an  operation  is  contra- 
indicated  for  any  good  reason,  the 
.r-rays  may  be  applied,  and  in  the  very 
earliest  stages  the  ulcer  sometimes  heals 
under  their  influence;  but  recurrence  is 
usual,  and  by  dilly-dallying  with  a>rays 
the  favorable  time  for  excision  may  be 
lost.  In  some  inoperable  cases  of  ex- 
ternal carcinoma  relief  may  be  secured 
by  desiccation  with  the  high  frequency 
current  by  radium  emanations,  or  by 
fulguration.  The  former  are  suitable  only 
for  surface  growths,  while  fulguration  is 
more  useful  for  deeply  seated  tumors 
after  curettement  or  partial  extirpation. 
2.  Superficial  Epithelioma  (Ro- 
dent Ulcer,  Jacob's  Ulcer). — This 
was  first  described  as  a  clinical  entity 
by  Jacob  of  Dublin  in  1827.  It  was 
first  recognized  as  a  variety  of  carcinoma 
by  Warren  in  1872.1 

1  Borst  and  other  pathologists  class  it  as  an  endothelioma  or  alveolar  sarcoma. 


Fig.  75. — Papillary  epithelioma 
(superficial  epithelioma  lately  show- 
ing more  malignant  characteris- 
tics); aged  seventy  years;  duration 
five  years.     Episcopal  Hospital. 


EPITHELIOMA 


125 


The  epithelial  cells  which  grow  down  from  the  skin  are  extremely 
atypical,  rounded,  polygonal,  or  even  spindle-shaped.  Because  they 
do  not  form  "epithelial  pearls,"  Krompecher  (1903)  has  named  this 
type  of  epithelioma  "basal-celled  carcinoma,"  on  the  theory  that  it 
is  the  only  type  formed  from  basal  cells;  but  Adami  contends  that  all 
epitheliomas  are  so  formed,  and  that  whereas  in  all  others  the  cells 
develop  to  the  horny  stage,  in  the  rodent  ulcer  the  cells  fail  to  do 
so  because  they  present  a  higher  degree  of  anaplasia. 

The  favorite  site  of  rodent  ulcer  is  on  the  upper  half  of  the  face, 
especially  near  the  ala  nasi,  on  the  lower  eyelid,  or  the  forehead;  it 
is  almost  unknown  on  other  parts  of  the  body.  It  is  often  preceded 
by  changes  in  the  skin  (keratosis,  etc.,  see  p.  669)  of  an  irritative 
character,  and  rarely  is  recognized  until  a  small  ulcer  has  formed, 


Fig.  76. — Rodent  ulcer  invading  or- 
bit, in  a  woman,  aged  thirty-five  years; 
duration  eighteen  months.  (Dr.  W. 
Walker's  case.)     Episcopal  Hospital. 


Fig.  77. — Rodent  ulcer;  duration  over 
five  years.  Eye  destroyed.  Had  so  far 
only  x-ray  treatment.  Now  inoperable 
Episcopal  Hospital. 


scabbed  over,  and  again  become  ulcerated  several  times.  The  ulcer 
spreads  very  slowly,  gives  little  discharge,  is  painless;  has  raised,  firm, 
glistening  edges;  and  occasionally  heals  in  one  part  while  extending 
in  another  (serpiginous  ulceration).  It  does  not  attack  the  neighbor- 
ing lymph  nodes,  and,  contrary  to  what  would  be  expected  from  its 
high  grade  of  anaplasia,  is  in  general  much  less  malignant  than  the 
deep-seated  epithelioma  just  described;  but  it  destroys,  surely  if 
slowly,  everything  in  its  course — eating  away  cartilage,  bone,  con- 
tents of  the  orbit,  opening  the  nasal  cavities  and  sometimes  exposing 
the  brain,  before  death  comes.  Sometimes,  after  progressing  slowly 
for  many  years,  the  rodent  ulcer  will  suddenly  take  on  rapid  growth, 
and  assume  the  character  of  a  deep-seated  epithelioma  (Fig.  75). 
Diagnosis. — It  must  be  distinguished  chiefly  from  the  deep-seated 
epithelioma.     In   rodent  ulcer  the  edges  are  harder,   more  raised, 


120 


TUMORS 


glistening,  and  sometimes  covered  with  fine  capillaries;  the  base  of 
the  ulcer  is  Hatter  and  not  so  deeply  placed;  secretion  is  less;  growth 
is  much  slower;  the  lymph  nodes  are  not  invaded;  and  microscopical 
examination  of  an  excised  portion  will  show  no  pearly  bodies,  and 
extremely  atypical  cells. 

Prognosis  is  good  with  proper  treatment  sufficiently  early. 

Treatment.  Excision  should  be  done,  but  it  is  not  necessary  to 
remove  the  adjacent  lymph  nodes.  Even  in  advanced  cases  com- 
plete excision  is  seldom  followed  by  recurrence,  so  that  operation 
should  not  be  refused  in  any  case  where  recovery  from  the  operation 
itself  seems  certain.  Very  early  treatment,  by  an  expert,  with  radium 
emanations,  frequently  causes  the  ulcer  to  heal  without  visible  scar; 
but  recurrence  is  not  unknown.  The  remarks  as  to  .r-ray  treatment, 
made  at  p.  124,  apply  here.  The  patient  shown  in  Fig.  77  had  been 
treated  for  fixe  years  with  the  .r-rays  before  she  came  to  me  for 
surgical  advice;  she  then  was  a  confirmed  alcoholic  and  morphino- 
maniac,  and  the  tumor  was  absolutely  inoperable. 


Fig.  78. — -Microscopic  appearance  of  adenocarcinoma  (cylindrical-celled 
carcinoma)  of  the  rectum.     (Lexer-Bevan.) 


Glandular  Carcinoma. — This  is  so  called  because  it  grows  in  glands. 
Two  forms  may  be  recognized,  according  to  the  extent  that  the  tumor 
departs  from  the  typical  glandular  form: 

1.  Adenocarcinoma. — The  less  atypical  forms,  known  as  adeno- 
carcinoma, are  composed  of  alveolar  spaces,  lined  with  cells  arranged 
around  their  periphery,  and  rarely  piling  up  on  each  other  so  as  to 
encroach  on  the  lumen.  This  form  is  therefore  known  also  as  columnar 
or  cylindrical-celled  carcinoma  (Fig.  78).  By  obstruction  of  the  ducts 
and  continued  secretory  action  of,  or  from  death  and  liquefaction  of 
the  cells,  these  alveoli  may  be  converted  into  cysts  (cystadeno-car- 


GLANDULAR  CARCINOMA 


127 


cinoma).  It  affects  especially  the  rectum,  pylorus  and  lesser  curvature 
of  the  stomach,  cecum,  etc.,  frequently  developing  from  preexisting 
ulcers  or  adenomas;  or  from  polypi,  when  it  is  wont  to  assume  a 
cauliflower-like  or  fungating  appearance.  It  occurs  also,  but  more 
rarely,  in  the  cervix  uteri,  naso-pharynx,  larynx,  and  gall-bladder; 
also  from  cell-rests  in  the  neck  (branchiogenic  carcinoma,  p.  731). 

2.  Solid-celled  Carcinoma. — The  most  atypical  form  of  gland 
carcinoma  consists  of  solid  plugs  of  epithelial  cells,- there  rarely  being 
any  lumen  whatever  (Fig.  79).  All  grades  may  exist  between  this 
form  and  that  previously  described.  Two  main  varieties  of  the 
solid-celled  carcinoma  are  recognized,  depending  upon  the  amount 


Fig.  7'.). —Microscopic  appearance  of  solid-celled  carcinoma,  arising  in  the  neck  of 
the  uterus.     (From  "Diseases  of  Women,"  Bland-Sutton  and  Giles.) 


of  stroma  present:  when  this  is  excessive,  the  tumor  is  said  to  be  a 
"scirrhus"  (scirrhous  carcinoma);  when  the  stroma  is  deficient,  and 
the  cellular  elements  conspicuous,  it  is  called  a  medullary  carcinoma, 
or,  from  its  gross  resemblance  to  the  brain  on  cross-section,  "  encepha- 
loid."  When  stroma  and  parenchyma  are  present  in  equal  amount 
it  is  described  as  carcinoma  simplex,  or  "acute  scirrhus."  Solid-celled 
carcinoma  affects  especially  the  mammary  gland  and  the  cervix  uteri, 
though  in  both  situations  various  combinations  of  carcinomatous 
growth  may  be  encountered. 

Gland  carcinoma  is  especially  prone  to  ulceration,  the  ulcer  being 
deeper  than  in  epithelioma,  and  there  being  a  much  greater  tendency 


128  TUMORS 

to  fungosity.  Colloid  degeneration  is  not  unusual,  particularly  in 
carcinomas  of  the  intestinal  tract;  it  is  due,  according  to  Adami,  to 
the  accumulation  within  the  cells  of  modified  mucin  which  they 
cannot  excrete,  the  result  being  that  entire  alveoli  may  be  distended 
with  this  glistening,  translucent  material. 

Symptoms. — The.  symptoms  of  gland  carcinoma  depend  so  much 
upon  the  seat  of  the  tumor,  that  their  description  is  best  postponed 
to  the  chapters  on  regional  surgery. 

Prognosis. — Untreated,  or  treated  only  palliatively,  the  expectation 
of  life  in  carcinoma  has  been  estimated  at  eighteen  months  for  the 
medullary,  and  two  and  one-half  years  for  the  scirrhous  variety;  for, 
although,  in  the  latter,  many  patients  survive  three,  five,  or  even  ten 
years,  yet  an  equal  number  die  in  less  than  the  average  period  men- 
tioned. The  prognosis  after  operation  will  be  discussed  with  regional 
surgery. 

Treatment. — All  operable  carcinomas  should  be  excised,  at  the 
earliest  possible  moment,  in  one  mass  with  the  neighboring  lymph 
nodes;  when  inoperable,  palliative  treatment  consists  in  dressing  the 
ulcer  (of  external  cancers)  with  permanganate  of  potash  or  other 
deodorant,  in  treatment  by  the  .r-rays,  and  in  giving  such  stimulants, 
tonics,  and  anodynes  as  shall  make  life  endurable.  Certain  palliative 
operations  are  applicable  to  inoperable  internal  carcinomas. 

Transitional  Lepidic  Tumors. — Mesothelioma  and  Endothelioma. — 
In  addition  to  the  classes  of  lepidomas  already  described  (derived 
from  epiblast  and  hypoblast),  Adami  places  in  a  separate  division 
those  tumors  derived  from  mesothelium  and  endothelium.  As  these 
were  themselves  derived  from  the  mesoblast,  and  as  this  in  turn  was 
formed  partly  by  epiblast  and  largely  by  hypoblast,  it  is  but  natural 
to  find  that  mesothelial  and  endothelial  tumors  present  at  times  the 
characters  of  lepidomas  (epi-or  hypoblast),  at  others  those  of  hylomas 
(mesoblast).  Therefore  they  are  well  named  transitional  lepidomas, 
because  while  they  usually  resemble  ordinary  lepidomas,  they  at 
times  in  whole  or  in  certain  parts  grade  so  imperceptibly  into  hylomas 
that  it  is  impossible  to  say  to  which  class  they  really  belong.  In 
this  group,  embryogenetically  at  least,  belong  the  lepidic  tumors  of 
the  uterus;  as  these  closely  resemble  similar  tumors  of  epiblastic 
(mammary)  and  hypoblastic  (intestinal)  origin,  Adami  supposes  that 
the  epiblast  has  overgrown  the  primary  mesoblast  of  the  genital  tract. 
These  tumors,  however,  frequently  appear  either  sarcomatous  (i.  e., 
mesotheliomatous)  or  endotheliomatous  in  parts,  so  it  is  evident  that 
they  possess  primary  mesoblastic  characteristics.  While  there  are 
typical  transitional  lepidomas  (adenoma),  the  tumors  in  this  group 
most  important  for  the  surgeon  are  atypical  (carcinomatous)  in 
nature.  Adenoma  and  carcinoma  of  the  prostate  are  included  in  this 
class,  as  well  as  rarer  tumors  of  the  ureters,  seminal  vesicles,  and  vas 
deferens;  similar  growths  of  adrenal,  kidney,  ovary,  and  uterus;  also 
mesothelioma  of  the  pleura,  etc.  For  reasons  already  given,  the 
tumors  of  the  uterus  resemble  usually  ordinary  gland  carcinoma.    The 


TRANSITIONAL  LE  PI  DO  MAS  129 

most  important  surgically  of  all  the  mesotheliomas  is  the  malignant 
growth  of  the  adrenal  gland  known  as  hypernephroma. 

Hypernephroma. — The  medulla  of  the  adrenal  develops  from  the 
nervous  system,  and  its  cortex  from  the  mesothelium,  closely  related  to 
that  which  forms  the  cortex  of  the  kidney.  The  adrenal  medulla  seldom 
gives  origin  to  atumor;  when  it  doesitforms  a  ganglioneuroma  (p.  1038.) 
The  hypernephroma  (alveolar  sarcoma,  angiosarcoma,  perithelioma, 
carcinoma,  etc.)  springs  from  the  adrenal  cortex,  and  is,  therefore, 
classed  as  a  mesothelioma.  In  it  may  be  clearly  seen  the  transitional 
type  from  carcinomatous  (lepidic)  to  sarcomatous  (hylic)  arrange- 
ment of  the  alveoli  (Fig.  80).  Owing  to  fetal  inclusions  in  ovary  or 
testis,  mesotheliomas  may  occur  also  in  those  organs,  and  more  rarely 
in  the  kidney  itself  (Chapter  XXV).  The  ordinary  hypernephroma 
behaves  as  a  malignant  tumor,  growing  sometimes  to  immense  size, 
invading  the  kidney,  and  possessing  firm  retroperitoneal  connections. 
The  only  treatment  is  prompt  excision,  which  implies  nephrectomy; 
the  operation  is  difficult  and  bloody,  and  recurrence  is  usual.  Bony 
metastases  occur,  occasionally  only  a  single  metastasis  (Scudder,  1910). 

nbnz1 


Fig.  80. — Hypernephroma  of  kidney.  Transition  from  adenomatous  to  sarcomatous 
type  of  growth:  nbnz',  adenomatous  overgrowth  of  solid  columns  or  masses  of  cells 
of  adrenal  type  nbnz",  transition  to  sarcomatous  arrangement;  K,  a  kidney  tubule 
involved  in  the  growth.    (Debernardi.) 

Mesothelioma. — Mesothelioma  may  arise  in  pleura,  peritoneum,  or 
rarely  in  pericardium  or  synovial  membrane.  The  rare  myeloid 
tumors  of  tendon  .sheaths  (Bellamy,  1901)  belong  here.  It  appears  as  a 
pseudo-inflammatory  thickening  of  the  serous  membrane,  producing  a 
flattened,  nodular  or  fungous  tumor,  composed  of  "elongated  acini, 
lined  with  irregular  swollen  cells  .  .  .  resembling  the  curiously 
epithelioid  type  of  cells  we  encounter  in  some  endotheliomas,"  these 
acini  lying  in  an  abundant  fibrous  stroma  (Adami).  I  have  known  a 
mesothelioma  of  the  pleura,  in  a  child  of  three  years,  to  be  mistaken 
for  empyema. 

Endothelioma.— From  this  class  should  be  excluded  blood  and  lymph 
vascular  changes  not  truly  blast omatous.  All  such  conditions  as 
9 


L30  TUMORS 

new,  telangiectases,  etc.,  will  be  discussed  under  surgery  of  the  vascular 
system  (p.  276).  Here  we  have  to  do  only  with  typical  and  atypical 
neoplasms  of  endothelial  tissues.  They  arc  classed  as  hemangeio- 
endothelioma  and  lymphangeio-endothelioma;  surgically  they  are  not 
of  much  interest.  Briefly,  they  are  formed  by  concentric,  and  at  times 
eccentric  proliferation  of  endothelium  of  blood  or  lymph  capillaries. 
An  atypical  hemangeio-endothelioma  of  the  inner  surface  of  the 
cranial  dura  mater,  in  which  calcareous  deposits  have  occurred,  is 
called  a  psammoma.  Perithelioma  is  a  tumor  in  which  the  lymph  cells 
lining  the  perivascular  lymph  spaces  proliferate;  when  hyaline  degen- 
eration occurs  in  these  cells,  the  tumor  is  called  a  cylindroma.  The 
growth  occurs  in  the  kidney,  bones,  and  skin.  Endothelioma  occurs 
oftenest  in  the  skin,  in  the  region  of  the  parotid,  in  the  genital  glands, 
bones,  lymph  nodes,  and  dura  (Park,  1907). 

Tumors  of  the  Carotid  Body  (p.  720)  tend  to  the  peritheliomatous  type. 

Melanoma. — There  is  great  uncertainty  whether  this  tumor  belongs 
among  sarcomas  or  not.  Adami  is  inclined  to  place  it  among  transi- 
tional lepidomas.  It  arises  by  atypical  proliferation  of  the  pigment- 
containing  cells  (chromatophores)  of  the  rete  Malpighii  in  the  skin, 
or  of  similar  cells  in  the  uveal  tract  of  the  eye.  Ordinary  pigmented 
nevi,  which  are  either  congenital  deformities,  or  typical  as  distin- 
guished from  atypical  melanomas,  sometimes  become  transformed 
in  adult  life  into  this  most  malignant  type  of  tumor.  Beginning  in 
a  cutaneous  nevus  or  in  the  eye,  a  melanoma  gives  rapid  and  wonder- 
fully widespread  metastasis,  by  both  blood  and  lymph  channels,  to 
skin,  internal  organs  (especially  liver),  bones,  lungs,  brain,  etc.  The 
only  treatment  is  wide  excision  or  amputation  before  metastasis  occurs. 

Cholesteatoma. — Cholesteatoma  is  a  tumor  regarded  by  Borst  and 
others  as  of  endothelial  origin;  others  (Ziegler)  think  it  ectodermic, 
resembling  ordinary  dermoid  cysts  (p.  132).  The  contents  consist 
of  "white,  pearl-like,  glistening  masses,  which  are  concentrically 
arranged,"  (Lexer)  apparently  the  remains  of  compressed  and  cornified 
epithelial  cells.  They  occur  in  the  middle  ear,  pia  mater,  and  urethra. 
They  vary  in  size  from  a  cherry  seed  to  a  hen's  egg.  They  may  cause 
pressure  symptoms  in  the  cranium,  or  otitis  media  when  in  the  middle 
ear.     Excision  is  the  best  treatment. 

CYSTS. 

A  cyst  is  an  abnormal  but  encapsulated  collection  of  fluid,  in  a 
cavity  which  is  not  provided  with  any  outlet.  The  fluidity  of  the 
contents  varies  from  liquid  to  semi-solid.  One  cavity  (unilocular) 
or  many  (multilocular)  may  exist.  A  cyst  is  to  be  distinguished  from 
an  abscess,  which  is  not  strictly  encapsulated;  from  dilatations  (ectasia) 
of  normal  channels  (varix,  aneurysm)  which  still  have  an  outlet;  from 
effusions  or  transudations  into  preformed  and  normal  cavities,  which 
are  classed  apart  (hydrops  articuli,  hydrocele,  hygroma,  hydrothorax, 
hydrocephalus,  etc.) — though  such  collections  may  be  encysted;  and 


CYSTS 


131 


from  cystomas,  which  is  a  term  sometimes  used  to  describe  neoplasms 
in  which  cysts  form  incidentally  (p.  120);  but  a  distinction  cannot 
always  be  made  clinically  between  cysts  and  cystomas. 

Cysts  may  be  classed  as  Extravasation,  Retention,  and  Parasitic 
Cysts.  All  cysts  tend  to  become  spherical  or  oval  unless  compressed 
by  neighboring  parts. 

Extravasation  Cysts. — These  are  encapsulated  collections  of  fluid 
not  in  a  preexisting  cavity.  An  example  is  the  hematoma,  due  to 
extravasation  of  blood,  which  as  the  result  of  reaction  and  condensa- 
tion in  the  surrounding  structures,  becomes  in  time  encapsulated. 
Certain  bursal  tumors  (p.  314)  may  belong  in  this  class.  Extravasa- 
tion of  lymph,  forming  a  chylous  cyst,  is  very  rare  (p.  207).  Extra- 
vasation of  urine  rarely  forms  a  distinct  cyst. 

Retention  Cysts. — Retention  cysts  arise  in  preexisting  cavities. 
They  form  the  largest  and  most  important  class,  and  may  arise  either 
because  there  is  no  opening  to  the  cavity,  or  because  the  normal 
opening  is  obstructed.  In  either  case  it  is  evident  that  secretion  or 
transudation  into  the  cyst  must  be  more  rapid  than  absorption. 
Generally  speaking,  these  cysts  may  be  classed  as  post-natal  or 
antenatal  in  origin. 


Fig.  81. — Sequestration  cyst,  or  dermoid  (congenital  abnormality)  of 
scrotal  raphe.     Episcopal  Hospital. 

I.  Of  Post-natal  Origin. — Examples  of  cysts  due  to  obstruction  of 

ducts  are   Cysts  of   Bartholin's   Gland,    Galactocele,    Sebaceous   Cysts, 

Hydronephrosis,     Hydrops   Vesicce    Fellea,    etc.     Examples  of  cysts 

formed  in  cavities  normally  having  no  outlet  are  corpora  Intea  and 

follicular  cysts  of  the  ovary,  cystic  goiter,  etc. 

Sequestration  Cysts  deserve  separate  mention.     They  are  due  to 
the  sequestration  and  detachment  of  portions  of  the  true  skin  either 


132  TUMORS 

(1)  during  ante-natal  development,  when  they  are  congenital,  and 
occur  along  the  fissural  lines  of  the  body;  or  (2)  are  caused  in  post- 
natal life  by  implantation  of  portions  of  the  true  skin  by  trauma. 
Most  dermoids  belong  to  the  former  class  (Fig.  81),  though  some, 
especially  pilo-nidal  cysts,  are  occasionally  of  post-natal  development. 
Implantation  dermoids  are  seen  in  the  fingers  of  sewing  women,  or 
in  the  faces  of  shavers.  I  have  several  times  excised  from  the  face 
cysts  supposed  to  be  wens,  which  on  opening  were  found  to  contain 
two  or  three  long  hairs  growing  from  the  interior  of  the  cyst  wall, 
which  in  such  cases  is  lined  with  squamous  epithelium,  not  with 
secreting  cells. 

II.  Of  Ante-natal  Origin. — These  may  be  considered  in  three 
divisions: 

1.  Cysts  Due  to  Persistence  of  Parts  of  Embryonic  Ducts. — Thyro- 
glossal,  Branchial,  Vitello-intestinal,  and  Urachal  Cysts:  the 
"Tubular  Cysts"  of  Bland-Sutton. 

2.  Cysts  of  Geniio-urinary  Passages: 

(a)  In  the  Male. — Encysted  hydrocele  of  testis,  probably  due  to  per- 
sistence of  the  embryonic  vasa  efferentia. 

(6)  In  the  Female. — From  various  tubules  composing  the  parova- 
rium, and  perhaps  from  the  paroophoron. 

3.  Congenital  Cysts  of  Glandular  Organs. — The  liver  and  kidney 
are  especially  affected.    The  pathology  is  obscure.     (See  p.  1038.) 

Parasitic  Cysts. — In  man,  two  main  varieties  of  parasitic  cysts 
are  found,  those  due  to  Trichina  Spiralis  and  Tenia  Echinococcus. 
The  trichina,  much  rarer,  forms  very  small  cysts,  oftenest  in  muscles 
(p.  308).  The  echinococcus,  commonly  known  as  hydatid  cysts,  may 
attain  an  immense  size.  This  parasite  is  an  inhabitant  of  the  intes- 
tinal tract  of  dogs,  and  the  ova  may  gain  entrance  to  the  digestive 
tracts  of  those  who  have  to  do  with  dogs  and  whose  habits  are  not 
very  cleanly.  It  is  a  rather  rare  disease  in  this  country.  The  shell  of 
the  ovum  is  dissolved  by  the  patient's  intestinal  juice,  and  the  larva, 
thus  liberated,  works  its  way  through  the  intestinal  mucosa  usually 
into  a  branch  of  the  portal  vein,  and  thus  reaches  the  liver;  here  it 
proliferates,  and  one  large,  or  innumerable  small  conglomerate  cysts 
will  be  found  depending  upon  the  stage  of  development.  They  are 
easily  recognized  by  the  "hooklets"  they  contain.  The  lungs,  brain, 
and  other  parts  of  the  body  may  also  be  affected.  Treatment  is 
discussed  in  Chapter  XXIV. 

GENERAL  REMARKS  ON  EXCISION  OF  TUMORS. 

The  incision  should  correspond  with  the  natural  folds  of  the  part; 
no  skin  need  be  removed  in  excising  benign  growths  unless  very  large, 
when  the  redundancy  may  be  removed  with  the  tumor  by  an  elliptical 
incision  or  one  in  the  form  of  double  SS  (Figs.  82  and  83).  If  a  tumor  is 
very  large,  it  is  not  wise  to  make  the  entire  incision  at  once,  as  bleeding 
is  more  easily  controlled  by  working  down  to  the  main  blood-supply 


GENERAL  REMARKS  ON  EXCISION  OF  TUMORS  133 

through  a  small  incision,  and  completing  this  when  the  main  vessels 
have  been  ligatecl.  Most  external  (i.  e.,  not  visceral)  tumors  are  exposed 
on  dividing  the  skin  and  superficial  fascia;  if  beneath  the  deep  fascia 
they  should  be  approached  through  the  proper  muscular  interspace. 
A  tumor  which  is  encapsulated  usually  may  be  enucleated,  keeping 
the  scalpel  close  to  the  capsule.  Malignant  tumors  necessitate  the 
removal  of  healthy  tissues  on  all  sides,  and  usually  of  the  overlying 
skin ;  as  they  frequently  extend  along  and  surround  large  bloodvessels, 
careful  dissection  is  required.  Cancers  should  not  be  removed  by 
blunt  dissection:  the  bruising  of  the  tissues  this  entails  causes  egress 
of  malignant  cells  into  the  surrounding  tissues.  A  malignant  tumor 
never  should  be  cut  into  in  the  process  of  removal;  to  do  this  may 
infect  the  entire  wound  with  cancer  cells,  and  may  cause  alarming 
hemorrhage  from  the  tumor  itself  wThich  it  will  be  very  difficult  to 
control.  If  a  tumor  when  exposed  is  found  to  be  so  placed  that  it 
cannot  be  removed  with  safety,  the  operation  must  be  abandoned; 


Fig.  82.     Elliptical  incision  for  the  Fig.  83. — Double  SS  incision  for  the 

removal  of  a  tumor.  removal  of  a  tumor. 

in  some  cases  the  pedicle  of  the  tumor  may  be  secured,  and  the  main 
bulk  cut  away;  or  the  main  vessels  may  be  ligated,  to  starve  the 
growth  (p.  705).  In  gastric  and  intestinal  tumors  a  palliative  opera- 
tion is  frequently  possible. 

If  a  tumor,  before  operation,  is  clearly  inoperable,  of  course  no 
attempt  should  be  made  to  remove  it.  Inoperability  may  depend 
on  general  conditions  (the  cachectic  state  of  the  patient,  and 
probability  or  certainty  of  metastases  which  will  kill  the  patient 
within  the  appointed  time  even  if  the  primary  growth  were  removed), 
or  on  the  local  condition;  fixity  of  the  growth,  especially  in  the  neigh- 
borhood of  great  vessels  is  always  a  sign  to  be  seriously  considered. 
It  is  important  for  the  surgeon  to  have  a  clear  understanding  with  his 
patient  as  to  the  extent  of  the  operation  possible  and  permissible. 
While  often  invading  and  obliterating  veins,  carcinoma  generally 
respects  arteries,  even  when  entirely  surrounding  them  (Crile) ;  so  that 
it  is  usually  possible  to  dissect  the  artery  free.     In  cases  where  it 


134  TUMORS 

may  become  necessary,  in  the  course  of  the  operation,  to  sacrifice  the 
main  artery  (especially  the  common  carotid,  Fig.  809)  the  tolerance 
of  the  patient  for  its  loss  may  be  determined  by  clamping  it  on  the 
proximal  side  of  the  growth  a  day  or  two  in  advance  of  the  opera- 
tion; if  in  the  meantime  threatening  symptoms  arise,  the  clamp  (Fig. 
233)  may  be  removed,  restoring  the  circulation.  Everything  but  life 
may  be  disregarded  in  operating  for  malignant  growths:  thus  it  is 
entirely  justifiable  to  amputate  the  thigh,  if  a  tumor  is  so  placed  as 
to  necessitate  excision  of  the  popliteal  artery,  which  would  surely 
cause  gangrene;  it  is  proper  to  excise  muscles,  tendons,  bones,  veins, 
arteries  and  even  nerves,  when,  as  in  the  neck,  to  do  so  will  bring  the 
operation  to  a  successful  conclusion  without  jeopardizing  life.  A 
patient  will  not  miss  one  pneumogastric  nerve  or  one  carotid  artery, 
and  as  a  rule  he  will  prefer  to  live  without  a  clavicle  and  with  a  power- 
less arm  than  to  keep  his  tumor  and  die.  In  some  tumors  resection 
of  the  thoracic  or  abdominal  wall  is  necessary;  the  greater  part  of  the 
stomach  may  have  to  be  removed  in  one  piece  with  the  transverse 
colon,  or  the  descending  duodenum  en  masse  with  the  head  of  the 
pancreas. 


CHAPTER    V 

SURGICAL  TECHNIQUE. 

There  are  readily  available  so  many  excellent  works  on  Band- 
aging, Antiseptic  and  Aseptic  Technique,  Minor  Surgery,  Anesthetics, 
etc.,  that  in  the  present  chapter  little  will  be  attempted  beyond 
discussing  briefly  the  principles  underlying  these  procedures. 

BANDAGING. 

Bandages  are  employed  to  hold  dressings  in  contact  with  a  wound, 
to  maintain  splints  in  position,  or  simply  to  support  the  part.  Those 
most  generally  useful  are  made  of  unbleached  muslin,  which  may  be 
torn  into  any  width.  For  the  fingers  a  bandage  should  be  2.5  cm.  in 
width;  for  the  head  and  neck,  5  cm.;  for  the  forearm,  7  cm.;  for  the 
arm  and  leg,  7.5  cm.;  for  the  thigh  and  shoulder,  8  cm.;  and  for  the 
trunk,  10  cm.  wide.  The  length  varies  with  the  part  to  be  bandaged 
and  with  the  purpose  for  which  the  bandage  is  employed;  the  finger 
bandages  are  usually  one  or  two,  and  the  larger  from  six  to  eight  meters 
in  length.  When  prepared  for  use  a  bandage  is  rolled  tightly  into  the 
form  of  a  cylinder  (roller  bandage),  the  free  end  being  known  as  the 
initial  extremity.  To  roll  a  bandage  by  hand,  fold  one  end  on  itself  for 
about  15  cm.;  again  fold  it  in  half,  thus  making  four  thicknesses  of  7.5 
cm.  each;  again  fold  it  in  half,  making  eight  thicknesses  3  cm.  long; 
and  keep  folding  the  bandage  on  itself  until  a  solid  core  is  formed. 
This  core  is  then  held  in  the  left  hand,  between  the  thumb  and  first 
two  fingers,  and  the  free  end  is  firmly  but  tightly  grasped  in  the  web 
of  the  right  thumb  (Fig.  84);  then  by  alternately  supinating  and 
pronating  the  left  hand,  rotating  the  roller  in  supination  but  relaxing 
the  grip  on  it  during  pronation,  the  free  end  of  the  bandage  is  guided 
on  to  the  roller,  which  increases  in  size  at  each  turn  of  the  hand. 
The  right  hand  should  keep  the  bandage  taut,  so  as  to  make  the 
roller  as  firm  as  possible.  A  mechanical  bandage  winder  is  useful  in 
hospitals  or  wherever  many  bandages  are  to  be  rolled. 

In  applying  a  bandage,  the  initial  extremity  is  placed  on  the  part, 
and  the  roller  carried  around  the  limb  transversely  from  left  to  right, 
once  or  twice,  to  fix  the  bandage.  As  the  bandage  gradually  covers 
the  part,  each  turn  should  be  so  applied  as  to  overlie  that  just  below 
by  one-third  or  more  of  its  width ;  when  it  is  found  impossible  to  make 
the  bandage  lie  flat  on  the  limb,  owing  to  the  conical  shape  of  the  latter, 
the  roller  is  to  be  carried  off  obliquely,  the  bandage  fixed  on  the  limb 
by  the  thumb  or  finger  of  the  left  hand,  and  the  bandage  reversed 

( 135 ) 


136 


SURGICAL  TECHNIQUE 


(Fig.  85).  If  the  limb  is  conical  it  may  be  necessary  (<>  apply  the 
initial  extremity  of  the  bandage  obliquely  in  order  to  fix  it  without 
making  a  reverse.  When  the  part  has  been  completely  covered  in, 
the  end  of  the  bandage  may  be  fastened  with  a  safety-pin  applied 
transversely  to  the  end  of  the  roller;  or  strips  of  adhesive  plaster  may 
be  used  instead.  Large  or  complicated  bandages  may  be  held  in  place 
by  stitching  instead  of  pins. 


Fig.  84. 


-Rolling  a  bandage  by  hand. 
(Wharton.) 


Fig.  85.- 


-Method  of  making 
(Wharton.) 


Fig.  86. — Method  of  removing  a  bandage.     (Whnrton.) 


In  removing  a  bandage,  nothing  is  so  clumsy  and  time  consuming 
as  to  drag  the  end  around  and  around  the  limb  as  a  long  streamer. 
The  entire  bandage  should  be  bunched  up  and  passed  from  hand  to 


BANDAGING 


137 


hand  as  it  is  unwound  (Fig.  86).  If  soiled,  it  may  be  removed  by  band- 
age scissors  (Fig.  87) ,  the  blunt  end  easily  slipping  between  the  folds 
of  bandage.  Care  should  be  taken  not  to  cut  over  a  subcutaneous 
bone  (e.  g.,  the  shin),  and  always  to  keep  the  blades  at  right  angles  to 
the  surface  of  the  limb,  for  fear  of  pinching  up  the  skin  between  them. 
As  a  general  rule,  bandaging  should  always  begin  below  and  proceed 
toward  the  trunk,  and  a  bandage  should  not  be  applied  to  a  limb 
without  covering  in  the  entire  limb  from  fingers  or  toes  up  to  and 
beyond  the  diseased  part.  In  limbs  slightly  diseased,  swelling  of  the 
distal  part  may  not  always  follow  the  careful  application  of  a  bandage 
to  the  affected  part  alone,  but  usually  the  whole  limb  is  more  or  less 
inflamed,  and  constricting  it  at  the  seat  of  greatest  swelling  may 
produce  marked  edema  of  the  distal  part  if  unsupported  by  the  band- 
age, and  cause  great  discomfort  to  the  patient.  Under  no  circum- 
stances should  a  bandage  be  applied  so  tightly  as  to  interfere  with 
the  circulation.  Hippocrates  taught,  and  it  is  still  absolutely  true, 
that  where  it  is  desired  to  give  pressure  to  a  part  by  means  of  bandages, 
it  is  much  safer  to  secure  this  by  employing  several  superimposed 
bandages  than  to  draw  the  primary  bandage  unduly  tight. 


Fig.  87. — Bandage  scissors. 

Gauze  bandages  are  much  employed  at  present;  but  they  are  inferior 
to  muslin  bandages  except  for  holding  dressings  lightly  in  place; 
they  are  of  most  use  for  the  head  and  neck,  because  they  are  so 
elastic  that  it  is  rarely  necessary  to  make  reverses.  But  if  drawn  at 
all  firmly  they  pull  into  strings  and  are  more  liable  than  muslin  to 
cause  injurious  constriction. 

Flannel  bandages  are  of  much  value  for  support  in  cases  of  edema, 
varicose  veins,  etc.  They  are  elastic,  especially  when  cut  on  the  bias, 
and  are  less  apt  to  irritate  the  skin  than  muslin  or  gauze.  Bandages 
of  elastic  icebbing  are  used  for  the  same  purposes. 

Varieties  of  Bandages. — The  bandages  most  frequently  employed 
are  the  spiral  or  spiral  reversed  (Fig.  85),  which  is  universally  used 
in  the  extremities;  the  recurrent  (Fig.  88),  used  for  stumps,  the  head, 
etc.;  the  spica  (Fig.  89),  which  is  employed  to  cover  the  shoulder, 
groin,  buttock,  etc.;  figure-of-eight  bandages  (Figs.  90,  91  and  92),  used 
to  cover  joints,  to  draw  the  shoulders  backward  or  forward,  etc.; 
T-bandages  (Fig.  93),  for  holding  dressings  to  the  perineum;  the 
many-tailed  bandage,  or  bandage  of  Scultetus  (1655)  (Figs.  94  and  95), 
especially  useful  for  abdominal    wounds   or  other  cases  where  the 


L38 


SURGICAL  TECHNIQUE 


patient  cannot  be  supported  while  a  roller  bandage  is  applied.  The 
application  of  these  various  bandages  is  sufficiently  indicated  in  the 
accompanying  figures. 


Fig.  88. — Recurrent  bandage. 
(Wharton.) 


Fig.  89. — Ascending  spica  bandage. 
(Wharton.) 


Fig.  90. — Figure-of-eight  bandage  of  the         Fig.  91. — Figure-of-eight    bandage  of 
knr>o.      (Wharton.)  the  neck  and  axilla.     (Wharton.) 


Fig.  92. — Posterior  figure-of-eight  bandage  of  the  chest.     (Wharton.) 


BANDAGING 


139 


Fixed  Dressings.— This  is  a  term  used  for  bandages  into  the  meshes 
of  which  some  substance  has  been  incorporated  which  on  drying 
becomes  stiff.  The  materials  usu- 
ally employed  are  starch,  silicate  of 
sodium,  or  plaster  of  Paris,  espe- 
cially the  last.  The  bandage  itself 
is  made  of  crinoline  or  coarse 
meshed  gauze. 

Plaster  of  Paris. — This  powder  is 
hygroscopic;  when  moistened  and 
allowed  to  dry  it  is  converted  into 
gypsum,  the  process  being  known 
as  setting.  It  is  worked  into  the 
meshes  of  the  bandage  by  a  spatula; 
the  bandage  is  then  loosely  rolled, 
tied  in  waxed  paper,  and  put  away 
in  an  air-tight  box  until  wanted. 
These  bandages  may  be  kept  thus 
for  several  weeks,  but  are  always 
better  when  freshly  made.  When 
it  is  desired  to  use  them,  one  band- 
age is  placed  on  end  in  hot  water 

which  completely  covers  it,  and  is  allowed  to  remain  in  the  water 
until  bubbles  cease  to  rise.    The  bandage  is  then  removed  from  the 


Fig.  93.— Double  tailed,  or  T-bandag 


Fig.  94. — Bandage  of  Scultetus  (many  tailed). 


Fig.  95. — Scultetus  bandage  applied;  overlapping  turns  fastened  with  safety- 
pins.     Episcopal  Hospital. 

water,  is  grasped  by  its  two  ends  in  the  hands,  and  is  squeezed  until 
nearly  dry.     It  is  then  applied  as  an  ordinary  roller  bandage  to  the 


I  III 


SURGICAL  TECHNIQUE 


part  (Fig.  90),  which  must  have  been  previously  protected  by  one  or 
two  layers  of  flannel  bandage  or  of  cotton  batting;  bony  prominences 
should  be  additionally  protected  by  raw  cotton  or  felt  pads.  A  suffi- 
cient number  of  plaster  bandages  should  be  applied  to  render  the 


Fiq.  90. — Plaster-of-Paris  bandage  being  applied  to  leg.    The  foot  should  be 
kept  at  a  right  angle  with  the  leg.     Orthopaedic  Hospital. 

bandage  firm  when  it  has  set.  Usually  four  to  six  are  required  for  the 
foot  and  leg,  eight  to  ten  for  the  knee,  and  twelve  or  more  for  the  pelvis 
or  trunk.  The  bandages  should  be  placed  in  the  water  only  as  needed ; 
they  set  quickly,  and  prompt  action  and  skilful  work  are  required  to 
make  a  satisfactory  gypsum  case,  or  "cast"  as  it  is  popularly  called. 


Fig.  97. — Removing  gypsum  case  by  means  of  Hunter's  saw.     Orthopaedic  Hospital. 

Before  the  last  bandage  is  applied,  the  projecting  margins  of  the 
underlying  flannel  bandage  may  be  turned  down  over  the  ends  of  the 
cast,  and  be  held  in  place  by  a  few  turns  of  the  last  bandage :  this  covers 
in  the  rough  edges  of  the  cast,  which,  unless  covered,  cause   great 


ANTISEPSIS  AND  ASEPSIS 


141 


annoyance  to  the  patient.  Finally  some  "plaster  cream"  may  be  rubbed 
all  over  the  surface  of  the  last  bandage:  this  is  made  by  adding  just 
enough  water  to  a  couple  of  handfuls  of  plaster  to  make  a  thick  paste. 
This  refinement  not  only  improves  the  appearance  of  the  cast,  but  by 
giving  it  a  glazed  surface  (enhanced  by  wiping  with  gauze  moistened 
in  alcohol)  keeps  the  cast  clean  much  longer.  The  gypsum  usually 
is  quite  firm  enough  in  half  an  hour  for  the  patient  to  be  moved  easily. 
Starch. — Starch  is  applied  in  the  form  of  a  paste,  by  rubbing  it  into 
the  bandages  as  they  are  applied.  It  is  much  more  brittle  and  liable 
to  break  than  gypsum,  but  may  be  used  as  a  top  dressing  to  a  soiled 
cast  which  it  is  undesirable  to  remove. 


Fig.  98. — Gypsum  dressing  trapped.     Orthopaedic  Hospital. 

Silicate  of  Sodium. — Silicate  of  sodium  is  a  pale  yellow  liquid  of  the 
consistency  of  mucilage.  It  is  best  applied  to  the  bandages  by  rolling 
them  on  a  winch  in  a  trough  full  of  the  liquid,  as  in  the  apparatus  of 
G.  G.  Davis.  Silicate  makes  a  light,  ornamental  cast,  possessing  all 
the  good  qualities  of  the  gypsum,  except  that  at  least  thirty-six  hours 
are  required  for  it  to  harden  completely.  It  is  much  cleaner  than 
plaster  of  Paris  and  is  readily  soluble  in  water. 

These  fixed  dressings  are  best  removed,  I  think,  by  the  use  of 
Hunter's  saw  (Fig.  97);  Avhen  the  gypsum  is  cut  to  the  underlying 
bandage,  a  fact  easily  detected  by  the  sensation  imparted  to  the  hand 
by  the  saw,  the  remaining  bandages,  and  any  part  of  the  cast  too 
soft  to  be  cut  by  the  saw,  may  be  cut  by  a  stout  pair  of  bandage 
scissors.  When  desirable,  a  cast  so  removed  may  be  sprung  off  and 
reapplied,  being  held  together  by  adhesive  straps  or  bandages.  The 
gypsum  may  be  cut  away  at  any  time  (most  easily  while  still  setting) 
to  make  a  "window"  or  "trap"  through  which  a  wound  may  be 
dressed  (Fig.  98). 


ANTISEPSIS  AND  ASEPSIS. 

In  order  to  prevent  entrance  of  microorganisms  into  wounds  at 
operation  or  other  times,  it  is  absolutely  necessary  to  take  such  pre- 
cautions as  will  kill  all  bacteria  which  might  be  introduced  through 
the  medium  of  instruments,  dressings,  or  the  hands  of  surgeons, 
assistants,  or  nurses;  or  from  the  skin  of  the  patient  himself,  or 


I  12  SURGICAL   TECHNIQUE 

from  septic  structures  within  his  body  invaded  during  the  course  of 
operation.  A  thing  is  sterile  when  there  are  no  bacteria  on  it,  or  when 
all  the  bacteria  on  it  are  dead.  Everything  that  has  not  been  sterilized 
is  considered  in  surgery  to  be  septic.  It  is  next  to  impossible  to  remove 
bacteria,  and  entirely  impossible  to  know  clinically  whether  all  the 
bacteria  have  been  removed  or  not.  The  only  recourse,  therefore, 
is  to  kill  them  all.  This  is  most  readily  accomplished  by  the  use  of 
moist  heat  (boiling),  as  no  bacteria  can  survive  a  temperature  of  over 
100°  C.  for  more  than  ten  to  fifteen  minutes.  Everything  that  can  be 
boiled  may  therefore  be  sterilized  in  this  way,  and  must  not  again 
be  touched  by  anything  septic;  if  it  is,  it  must  be  re-sterilized  Before 
it  can  be  used  safely.  Instruments,  basins,  buckets,  etc.,  are  readily 
sterilized  by  boiling.  Enough  sodium  carbonate  (washing  soda) 
should  be  placed  in  the  water  to  prevent  oxidation  (rusting)  of  the 
instruments  (15  gm.  to  a  liter).  Dressings  may  be  treated  in  the 
same  way,  but  as  they  take  much  longer  than  instruments  to  cool 
off,  and  are  nearly  useless  when  wet,  it  is  much  more  satisfactory  to 
sterilize  such  things  in  a  steam  autoclave.  For  this  purpose  they 
are  loosely  wrapped  in  an  outer  covering,  which  is  undone  after  they 
have  been  sterilized,  and  the  contents  of  the  package  are  removed 
only  by  sterile  hands  or  instruments  at  the  time  of  operation.  If 
carefully  wrapped  and  kept  so,  such  dressings  may  be  preserved  in  a 
sterile  state  for  several  days  at  a  time;  though  it  is  always  safer  to 
re-sterilize  them  on  the  day  of  the  operation.  As  the  temper  of  knives 
is  readily  spoiled  by  boiling,  and  as  their  surfaces  are  smooth  and 
therefore  readily  cleansed  mechanically,  I  think  it  is  best  to  use 
chemicals  to  sterilize  them;  placing  them  for  twenty  minutes  in  hot1 
carbolic  acid  solution  (5  per  cent.)  and  then  in  alcohol  (70  per  cent.) 
until  used. 

The  hands  of  the  surgeon  and  his  assistants,  and  the  skin  of  the 
patient,  however,  cannot  be  sterilized  by  heat ;  they  must  be  prepared 
by  mechanical  and  chemical  processes.  (When  a  surgeon  speaks  of 
his  hands,  he  should  use  the  term  in  the  sense  of  the  Greek  word  yjl,°, 
which  meant  the  hands  and  forearms  up  to  and  including  the  elbows.) 
The  hands  are  best  prepared  by  washing  in  hot  soapsuds,  with  careful 
use  of  a  nail-brush,  for  ten  minutes;  then  the  soap  is  rinsed  off,  and 
further  removed  by  rubbing  the  hands  and  forearms  with  alcohol. 
The  patient's  skin  is  prepared  in  the  same  say,  and  is  covered  with 
dry  sterile  gauze  until  the  time  of  operation.  The  mechanical  cleans- 
ing with  the  nail-brush,  aided  by  the  macerating  effect  of  heat  and 
soapsuds,  removes  all  loose  epithelium  and  probably  removes  almost 
all  the  germs  present.  The  alcohol  by  its  dehydrating  effects  opens  up 
the  orifices  of  the  cutaneous  glands  and  allows  penetration  of  the 
skin  more  effectively,  thus  weakening,  if  not  killing,  the  germs 
always  present  in  the  deeper  layers.  Most  surgeons  in  this  country 
prefer  to  wear  over  their  hands  thin  rubber  gloves  which  have  been 

1  It  is  worth  noting  in  this  place  that  all  antiseptic  solutions  are  much  more 
efficient  when,  hot  than  if  cold  or  merely  luke-warm. 


ANTISEPSIS  AND  ASEPSIS  143 

properly  sterilized.  There  is  no  doubt  that  they  are  a  most  valu- 
able addition  to  the  surgical  armamentarium,  chiefly  as  a  protection 
to  the  surgeon  from  contamination  in  septic  cases.  The  use  of  gloves 
in  no  way  absolves  the  surgeon  from  careful  preparation  of  his  hands, 
but  it  enables  him  in  emergency  to  pass  from  a  septic  to  an  aseptic 
operation  with  an  impunity  which  can  never  be  enjoyed  when  he 
operates  with  bare  hands.  All  persons  concerned  in  the  operation 
wear  sterile  gowns,  and  caps,  and  the  operators  wear  face  masks  of 
gauze  to  prevent  contamination  of  the  wound  or  the  instruments  or 
dressings  in  any  conceivable  manner. 

Iodin  Disinfection. — Grossich  in  1908  found  if  the  patient's  skin 
(without  previous  preparation  except  dry  shaving)  were  painted  with 
a  10  to  12  per  cent,  alcoholic  solution  of  iodin  shortly  before  operation, 
at  the  time  of  operation,  and  at  the  close  of  the  operation,  the  wounds 
healed  better  than  after  the  habitual  methods  of  skin  preparation. 
This  method  is  popular  for  its  simplicity  and  efficiency,  and  is  now  in 
general  use.  Most  surgeons  find  an  alcoholic  solution  of  from  3  to  5 
per  cent,  strong  enough,  but  many  do  not  sufficiently  appreciate  the 
fact  that  the  skin  must  be  dry,  to  permit  penetration  of  the  iodin.  It 
must  not  have  been  wet  for  three  or  four  hours  at  least.  It  is  im- 
portant not  to  use  iodin  whose  strength  has  been  increased  by  evapora- 
tion, and  not  to  cover  the  areas  painted  with  iodin  until  the  latter  lias 
dried.     Either  error  may  cause  blistering  of  the  skin. 

Picric  Acid,  in  2  per  cent,  solution,  may  be  used  in  the  same  way 
as  iodin. 

Antiseptic  Methods  of  Operating  were  introduced  before  aseptic 
methods  (Lister,  1865;  Lucas-Championniere,  1869,  1876),  and  are 
still  most  widely  applicable.  Here,  after  preparing  the  dressings, 
instruments,  and  skin  as  above,  the  surgeon  keeps  his  instruments 
in  antiseptic  solutions  (2.5  per  cent,  carbolic  acid);  uses  sponges 
soaked  in  antiseptics  for  mopping  out  the  wound;  and  at  the  con- 
clusion of  the  operation  applies  a  stronger  antiseptic  solution  (3.5 
per  cent,  iodin,  5  per  cent,  carbolic  acid,  5  or  10  per  cent,  zinc 
chloride,  1  to  1000  corrosive  sublimate,  etc.)  to  the  entire  surface 
of  the  wound.  In  this  way  he  makes  sure  that  any  microorganisms 
introduced  into  the  wound,  accidentally,  will  have  an  unfavorable 
soil  for  growth,  and  that  in  all  probability  they  will  be  so  weakened 
by  the  antiseptics  employed  as  easily  to  be  killed  by  the  tissues  of 
the  body.  This  method  of  operating  is  applicable  to  all  primarily 
septic  conditions  (compound  fractures,  necrosis,  abscesses,  malig- 
nant tumors,  most  amputations,  etc.),  and  is  valuable  in  a  some- 
what modified  form  in  all  operations  where  the  tissues  are  much 
bruised  or  long  exposed  to  the  atmosphere  during  the  course  of  the 
operation  (some  excisions,  ununited  fractures,  tedious  dissections, 
etc.).  When,  however,  the  operation  is  of  short  duration  (under 
half  an  hour),  or  when  the  tissues,  even  during  a  longer  operation, 
are  not  bruised  or  otherwise  unduly  injured,  and  especially  in  visceral 
surgery,  the  aseptic  method  is  superior. 


141  SURGICAL   TECHNIQUE 

Aseptic  Methods  of  Operating  have  been  in  general  use  only  for  the 
last  fifteen  or  twenty  years,  and  were  systematized  largely  by  Terrier 
and  his  pupils.  The  instruments,  dressings,  etc.,  are  sterilized,  and  the 
instruments  are  placed  in  sterile  water  or  laid  on  a  table  covered  with 
sterile  sheets.  The  hands  and  the  patient's  skin  are  prepared  in  the 
usual  way,  but  no  antiseptics  whatever  are  used  during  the  course  of 
the  operation;  everything  coming  into  contact  with  the  wound  is 
sterile;  and  it  depends  on  the  unceasing  and  seemingly  pedantic  pre- 
cautions of  the  surgeon  to  keep  the  wound  aseptic.  If  one  mis-step 
is  made,  the  aseptic  has  to  be  abandoned  for  the  antiseptic  method; 
and  while  I  think  the  surgeon  should  always  employ  the  aseptic  method 
when  he  safely  can,  because  antiseptics  are  at  times  harmful  to  the 
patient,  and  occasionally  delay  the  process  of  repair,  yet  it  cannot  be 
denied  that  adherence  to  a  strictly  aseptic  technique  is  much  more 
difficult;  and  it  must  be  acknowledged  that  many  surgeons  seem  incap- 
able of  practising  it  thoroughly.  When  either  method  is  properly 
employed,  the  wound  heals  without  noticeable  inflammatory  reaction, 
no  stitch  abscesses  form,  no  discharging  sinuses  remain,  no  ligatures 
are  slowly  eliminated  from  its  depths,  no  granulations  persist  at  one 
end  of  the  incision,  the  comfort  of  the  patient  is  enhanced,  and  the 
after-treatment  much  simplified. 

MINOR  SURGERY. 

Counter-irritation. — Counter-irritation  is  conveniently  secured  by 
the  use  of  very  hot  compresses,  by  turpentine  stupes,  or  by  means 
of  plasters  of  mustard,  capsicum,  etc.  While  these  remedies  are 
merely  rubefacient  in  their  effect,  cantharides  plaster  will  produce  a 
blister  (vesication);  the  surface  of  the  plaster  should  be  wiped  with 
olive  oil  or  petrolatum,  so  as  to  prevent  it  sticking  to  the  cuticle. 
It  should  be  removed  in  six  or  eight  hours,  and  the  blister  will  com- 
monly draw  for  several  hours  more;  meanwhile  it  should  be  dressed 
lightly  with  an  ointment,  and  when  fully  draw-n  the  tense  cuticle 
should  be  punctured  with  an  aseptic  bistoury,  and  allowed  to  collapse 
on  to  the  face  of  the  blister  as  the  serum  exudes.  When  the  blister 
shows  a  tendency  to  dry  up,  this  may  be  encouraged  by  applying  talc 
or  other  dusting  powder.  Cauterization  is  readily  secured  by  means 
of  the  actual  cautery.  To  produce  vesication  or  still  slighter  degrees 
of  counter-irritation,  it  is  sufficient  merely  to  touch  the  skin  with 
the  cautery  iron  when  at  a  cherry  red  heat,  or  even  to  hold  it  close 
to  the  skin  without  bringing  the  iron  into  actual  contact  with  it. 

Acupuncture. — Acupuncture  is  a  little  operation  sometimes  used 
in  cases  of  lumbago,  etc.  After  preparing  the  patient's  skin  as  for  an 
operation,  six  to  ten  sterile  needles  (ordinary  hat  pins  will  do)  are 
thrust  into  the  loins  with  a  quick  boring  motion,  and  are  allowed  to 
remain  in  place  a  few  minutes.  Care,  of  course,  must  be  exercised  not 
to  injure  any  superficial  vein,  nerve,  etc.,  and  not  to  enter  the  spinal 
canal.    No  anesthetic  is  required- 


MINOR  SURGERY  145 

Vaccination. — Vaccination,  though  usually  done  by  the  family 
physician,  is  a  surgical  procedure.  The  method  I  prefer  is  the  follow- 
ing: the  skin  of  the  arm  is  rubbed  briskly  with  an  alcohol  sponge,  and 
vigorously  dried  with  sterile  gauze;  this  arouses  the  circulation  of  the 
part,  and  makes  the  virus  more  apt  to  "take."  Then  with  the  belly  of 
an  aseptic  and  rather  dull  scalpel,  the  cuticle  is  scraped  oft'  over  an 
area  about  1  cm.  square  until  the  surface  is  moist.  Xo  blood  should 
be  drawn.  The  vaccine  is  then  quickly  applied,  and  rubbed  into 
the  abraded  area  by  means  of  the  glass  tube  in  which  it  is  supplied. 
The  vaccinated  area  is  allowed  to  dry,  completely,  in  the  air,  and 
no  shield  or  bandage  is  employed.  The  wound  should  be  painted 
every  second  or  third  day  with  a  3  per  cent,  solution  of  iodin. 

Hypodermic  Injections. — Convenient  tablets  containing  the  requi- 
site amount  of  the  drug  are  easily  obtained  from  manufacturers. 
The  tablet  is  dissolved  in  2  c.c.  of  sterile  water  or  saline  solution, 
or  the  water  with  the  tablet  in  it  may  be  sterilized  in  a  spoon 
over  a  flame.  The  fluid  is  then  drawn  up  into  the  barrel  of  the  hypo- 
dermic syringe  previously  sterilized  by  boiling  or  by  soaking  in  an 
antiseptic  solution  (which  should  of  course  have  been  removed  by 
rinsing  the  interior  of  the  syringe  in  sterile  water).  The  sterilized 
hollow  needle  is  then  screwed  on  to  the  nozzle  of  the  syringe,  and 
any  bubbles  of  air  are  expelled  by  pressure  on  the  piston,  while  the 
needle  is  held  upward,  until  the  fluid  spurts.  Then  a  fold  of  the 
patient's  skin,  prepared  by  vigorous  rubbing  with  an  alcohol  sponge, 
is  picked  up  between  the  thumb  and  finger  of  the  left  hand,  and  the 
needle  quickly  thrust  obliquely  into  this  fold,  so  that  the  point  enters 
the  subcutaneous  tissues.  Care  must  be  taken  to  avoid  entering  a 
subcutaneous  vein,  wounding  a  nerve,  etc.  The  best  situations  for 
hypodermic  injections  are  over  the  deltoid  muscle,  on  the  outer 
surface  of  the  thigh  or  calf,  in  the  buttocks,  the  loins,  or  the  lateral 
abdominal  wall.     No  dressing  is  required  for  the  needle  puncture. 

Use  of  Saline  Solution. — The  object  of  this  solution  is  to  supply 
a  fluid  as  nearly  like  the  blood  as  possible.  The  following  formula  is 
recommended  by  Park: 

1$ — Calcium  chloride,  2  parts 

Potassium  chloride,  3  parts 

Sodium  chloride,  9  parts 

Sterile  water,  1000  parts 

This  should  be  prepared  aseptically  and  should  again  be  sterilized 
before  use.  In  emergencies  it  is  sufficient  to  add  a  teaspoonful  of 
sodium  chloride  (table  salt)  to  each  half  liter  of  water,  boiling  the  solu- 
tion before  using.  This  fluid  is  used  hypodermically  ( hy-podermoclysis  I , 
by  the  bowel  {proctoclysis),  and  by  intravenous  infusion.  It  is  also 
widely  employed,  especially  in  abdominal  surgery,  as  a  substitute  for 
sterile  water.  It  should  be  injected  at  a  temperature  of  from  105° 
to  110°  F.  For  hypodermoclysis,  proctoclysis,  or  intravenous  use, 
it  is  convenient  to  let  it  flow  out  of  a  glass  jar  graduated  from  above 
downward,  so  that  a  glance  will  show  how  much  has  been  given. 
10 


146  SURGICAL  TECHNIQUE 

In  emergencies,  a  sterile  fountain  syringe  or  funnel  will  answer  the 
purpose.  The  main  purposes  for  which  it  is  used  are  to  combat  hem- 
orrhage and  shock  by  restoring  blood  pressure  (p.  265),  and  to  dilute 
toxins  circulating  in  the  blood. 

Hypodermoclysis.-  This  is  the  subcutaneous  instillation  of  saline 
solution.  A  long  hollow  needle,  with  large  caliber,  is  used ;  it  is  attached 
to  a  rubber  tube  connecting  with  the  receptacle,  which  may  be  several 
feet  higher  than  the  patient.  The  clip  on  the  tube  is  released,  and, 
while  the  fluid  is  running  from  the  needle,  this  is  thrust  into  the  sub- 
cutaneous tissues  as  in  administering  a  hypodermic  injection.  The 
best  sites  for  hypodermoclysis  are  under  the  mammary  glands,  in  the 
flanks,  the  lateral  abdominal  walls,  or  between  the  scapulae.  From 
250  to300c.c.  may  be  introduced  through  one  puncture,  the  accumulat- 
ing fluid  being  gently  rubbed  out  into  the  tissues.  Rarely  more  than  one 
liter  is  required  by  hypodermoclysis.  The  fluid  is  not  absorbed  very 
rapidly,  and  where  immediate  effect  is  desired  it  should  be  given 
intravenously.  The  needle  punctures  should  be  painted  with  collo- 
dion and  sealed  with  a  scab  of  absorbent  cotton.  Under  the  term 
axillary  infusion  has  been  described  a  method  of  hypodermoclysis  by 
which  absorption  is  very  rapid:  a  puncture  is  made,  with  a  bistoury, 
through  the  skin  over  the  pectoralis  major  muscle  about  midway 
between  the  clavicle  and  anterior  axillary  fold;  then,  with  the  fingers 
of  the  left  hand  in  the  armpit  as  a  guide,  an  infusion  cannula  (not 
dangerous  because  blunt)  is  thrust  through  this  puncture  into  the 
cellular  tissues  of  the  axilla,  traversing  the  pectoral  muscle;  the 
solution  is  then  allowed  to  flow. 

Proctoclysis. — Proctoclysis,  the  rectal  instillation  of  saline  solution,1 
is  widely  employed  in  the  treatment  of  peritonitis  (Murphy,  1905). 
A  soft  rubber  catheter  is  attached  to  the  rubber  tube  leading  from  the 
reservoir,  which  should  not  be  more  than  a  few  inches  higher  than  the 
patient's  buttocks;  the  eye  of  the  catheter  is  placed,  just  within  the 
anus.  The  solution  should  flow  into  the  rectum  very  slowly,  about 
750  c.c.  every  forty  to  sixty  minutes  for  an  adult.  If  750  c.c. 
of  the  solution  are  placed  in  the  reservoir  every  two  hours,  9  liters 
will  be  absorbed  in  a  day,  and  the  rectum  will  have  periods  of 
rest  of  an  hour  or  more  after  each  amount  has  been  absorbed.  The 
catheter  is  to  remain  in  place  continuously.  This  treatment  may 
be  continued  for  four  or  five  days  if  necessary.  If  too  much  fluid  is 
administered,  slight  edema  of  the  ankles,  hands,  and  even  face  may 
appear  (Murphy).  The  solution  is  placed  in  the  container  hot  (105° 
to  110°  F.),  and  may  be  kept  hot  by  hot  water  bags  (Fig.  889) ;  but  it 
is  probable  that  owing  to  its  slow7  flow,  it  is  about  the  temperature  of 
the  blood  or  lower  after  traversing  the  tube  to  the  patient. 

Intravenous  Infusion. — Select  a  superficial  vein  (usually  the  median 
cephalic  at  the  elbow),  and  tie  a  tight  bandage  around  the  extremity 
on  the  cardiac  side  of  the  vein  selected,  in  order  to  render  it  visible 

1  Sterile  water,  without  the  addition  of  salines,  is  just  as  efficient;  it  is  not 
irritating  to  the  bowel  and  is  absorbed  as  readily  (Trout,  1912). 


MINOR  SURGERY 


147 


and  fulhr  distended.  Prepare  the  skin  and  your  hands  in  the  usual 
way.  With  a  fine  sharp  pointed  hollow  needle  make  a  quick  thrust 
through  the  skin,  and  endeavor  to  reach  the  lumen  of  the  vein.  This 
requires  considerable  skill  and  practice.  It  is  sometimes  better  to  make 
an  incision  somewhat  obliquely  to  the  course  of  the  vein,  about  3  cm. 
long,  and  cut  down  with  light  strokes  directly  on  to  the  vein,  which 
may  be  embedded  in  fat.  Do  not  tease  and  maul  the-fat;  this  favors 
infection  of  any  wound.  When  the  vein  is  thoroughly  exposed  in  this 
way,  thrust  a  grooved  director  across  beneath  the  vein,  and  along  the 
groove  slip  two  ligatures.  Draw  one  of  the  ligatures  to  the  distal 
side  of  the  grooved  director  and  ligate  the  vein;  draw  the  other  liga- 
ture upward,  on  the  cardiac  side  of  the  director,  and  loop  it  but  do 
not  tie  it  tight.     Then  pass  a  sharp  scissors  along  the  grooved  director 


Fig.  99. — Intravenous  infusion  of  saline  solution. 


and,  controlling  the  blood  by  a  finger  of  the  other  hand  on  the  cardiac 
side  of  the  director,  cut  the  vein  half  way  across  (Fig.  99).  Lay 
aside  the  scissors,  and  take  the  infusion  cannula  (blunt  pointed, 
with  bevelled  eye)  in  the  right  hand,  have  the  clip  removed  from 
the  tube,  and,  while  the  saline  solution  is  running  from  the  cannula, 
gently  insert  this  into  the  gaping  wound  in  the  vein,  pointing 
it  toward  the  heart,  and  tie  the  ligature  already  placed  so  as  to 
secure  the  cannula  in  the  vein.  Then  withdraw  the  grooved  director 
and  have  the  bandage  around  the  limb  cut,  so  as  to  allow  the  venous 
current  to  flow.  The  reservoir  should  not  be  held  more  than  a  foot 
or  two  above  the  patient's  body,  and  the  saline  solution  should  not 
flow  more  rapidly  than  500  c.c.  in  ten  minutes.  The  amount  introduced 
must  depend  on  the  state  of  the  patient's  pulse.  Usually  a  liter  is 
more  than  enough;  occasionally  several  liters  will  be  required. 

Transfusion  of   Blood. — Direct   transfusion,   introduced    by    Crile 
(1906),  implies  the  transference  of  blood  directly  from  an  artery  of  a 


148  SURGICAL   TECHNIQUE 

healthy  person  (known  as  the  donor)  to  a  vein  of  the  patient  (the 
recipient).  It  lias  been  almost  entirely  superseded  by  indirect  tnnis- 
fusum,  an  old  method  recently  revived  with  improvements,  in  which 
blood  is  first  drawn  into  a  receptacle,  and  then  injected  into  the 
patient's  veins.  It  is  necessary  to  prevent  clotting  of  the  blood 
during  the  process.  This  is  accomplished  in  two  main  ways:  (1)  By 
drawing  the  blood  directly  into  a  paraffin-coated  flask,  and  reinjecting 
it  immediately  by  transferring  this  Mask  to  the  recipient  (Kimpton, 
L913).  The  paraffin  mixture  is  composed  of:  Stearin,  1  part;  paraffin, 
2  part-;  vaselin,  2  parts  (Beth  Vincent,  1912).  (2)  By  the  citrate 
method  popularized  by  Lewisohn  (191.")):  add  slowly  to  the  blood,  as 
it  is  drawn,  in  the  ratio  of  1  to  10,  a  2  per  cent,  solution  of  sodium 
citrate,  which  prevents  coagulation.  The  selection  of  the  donor  is 
important;  to  obviate  the  possibility  of  hemolysis,  his  blood  should 
conform  to  the  same  type  as  that  of  the  recipient;  and,  of  course,  he 
should  be  not  only  free  from  disease,  active  or  latent,  but  strong  and 
husky.  In  hospitals  the  clinical  pathologist  should  keep  a  list  of 
available  donors,  and  one  of  the  proper  type  may  be  selected  when 
occasion  demands.  Lewisohn  thus  describes  his  citrate  method: 
The  donor  is  put  on  a  table,  a  tourniquet  applied  to  the  arm,  and  the 
vein  punctured  with  a  large  size  cannula  (gauge  11).  The  blood  is 
received  in  a  sterile  graduated  glass  jar  (500  c.c.)  containing 25  c.c.  of 
a  2  per  cent,  sterile  solution  of  sodium  citrate.  While  the  blood  is 
running  it  is  well  mixed  with  the  citrate  solution  by  a  glass  rod.  After 
250  c.c.  of  blood  have  been  taken  another  25  c.c.  of  citrate  solution 
are  added,  and  blood  up  to  500  c.c.  drawn.  The  citrated  blood  is  then 
taken  to  the  recipient,  whose  vein  is  punctured  or  exposed  by  a  small 
incision,  and  the  citrated  blood  is  slowly  introduced  by  gravity.  It 
is  possible  to  preserve  this  citrated  blood  in  cold  storage  for  as  long 
as  twenty-four  or  forty-eight  hours  before  using  it. 

Phlebotomy. — Phlebotomy  which  is  usually  preferred  to  arteriotomy 
for  "letting  blood,"  is  generally  done  in  the  median  cephalic  or  median 
basilic  vein.  The  vein  is  made  tense  by  applying  a  tight  bandage 
above  it,  the  skin  is  properly  prepared,  and  a  small  incision  (1  cm.) 
is  made  directly  over  and  into  the  vein.  No  anesthetic  is  required. 
The  spurting  blood  is  caught  in  a  suitable  basin;  it  may  be  made 
to  run  more  freely  by  having  the  arm  dependent  or  by  directing  the 
patient  to  work  his  fingers  around  a  bar,  alternately  tightening  and 
loosening  his  grip.  The  patient  should  be  in  a  sitting  posture,  so  that 
any  faintness  may  be  quickly  perceived.  It  is  seldom  desirable  to 
draw  more  than  half  a  liter.  The  wound  is  dressed  with  a  pledget  of 
sterile  gauze,  no  suture  being  required;  and  the  same  wound  may 
easily  be  reopened  for  further  bleeding  during  the  next  few  days. 

Leeching. — The  Swedish  leech,  which  is  preferred,  draws  from 
1(1  to  1.")  c.c.  of  blood.  The  skin  is  carefully  washed,  and  the  leech 
applied  over  the  part  to  be  leeched,  but  not  directly  over  a  super- 
ficial vein.    If  the  leech  does  not  bite,  a  little  milk  or  blood  should  be 


ANESTHESIA  AND  ANESTHETICS 


149 


placed  on  the  skin.  When  he  has  drunk  his  fill  he  will  fall  off;  or  this 
may  be  hastened  by  applying  salt  over  the  leech  and  neighboring  skin. 
The*  blood  usually  continues  to  flow  for  some  time,  so  that  a  much 
larger  quantity  may  be  drawn  from  one  leech  bite  than  the  capacity  of 
the  leech.  When  enough  has  been  drawn,  the  bite  should  be  dressed 
antiseptically,  and  moderate  pressure  applied. 

Aspiration. — By  means  of  a  vacuum  bottle  it  is  easy  to  withdraw 
fluid  collections  through  a  hollow  needle.  Water  pressure  may  be 
used  to  produce  a  vacuum,  by  attaching  the  exhaust  tube  to  a  hydrant 
of  running  water  by  means  of  a  suitable  connection,  or  an  ordinary 
suction  pump  may' be  used  (Fig.  100).  The  bottle  is  first  emptied 
of  air  as  far  as  possible;  the  valves  are  then  turned,  and,  the  skin 
having  been  properly  prepared,  the  sterile  trocar  and  cannula  are 
thrust  through  the  overlying  tissues  into  the  collection  of  fluid  (hydro- 
thorax,  empyema,  cold  abscess,  etc.).  The  trocar  is  then  withdrawn, 
the  valve  turned  to  close  its  passage,  and  the  valve  leading  from  the 
cannula  to  the  bottle  is  opened,  allowing  the  fluid  to  flow.  If  the 
lumen  of  the  cannula  is  blocked  by  flakes  of  lymph,  a  stylet  may  be 
passed  through  it  from  time  to  time.  The  puncture  should  be  dressed 
antiseptically. 


Fig.  100. — Aspiration  of  a  lumbar  abscess.     Episcopal  Hospital 


ANESTHESIA  AND  ANESTHETICS. 

Certain  gases,  which  are  respirable,  induce  unconsciousness  when 
absorbed  through  the  lungs  and  carried  to  the  nerve  centers.  The 
state  so  produced  is  called  general  anesthesia.  In  addition  to  uncon- 
sciousness, which  implies  analgesia  and  anesthesia,  muscular  relaxa- 
tion is  also  produced.1  It  is  possible  to  secure  the  same  effects  from 
some  such  drugs  when  administered  otherwise  than  by  inhalation,  as 
by  rectal  administration;  but,  as  a  rule,  general  anesthesia  is  secured 

1  Crile  maintains  that  general  anesthesia  secured  in  the  usual  way  does  not 
prevent  nocuous  impulses  from  the  seat  of  operation  reaching  the  brain  along 
afferent  nerves.  If,  however,  the  usual  methods  adopted  to  secure  local  anesthesia 
are  added  to  the  general  anesthetic  these  nocuous  associations  are  avoided.  To 
this  principle  of  operative  surgery  he  has  given  the  name  Anoci-association. 


150  SURGICAL  TECHNIQUE 

by  inhalation  of  the  vapor  of  ether,  chloroform,  ethyl  chloride,  etc. 
Local  anesthesia  is  produced  by  the  local  use  of  some  drug,  usually 
introduced  by  hypodermic  injection,  which  acts  on  the  peripheral 
nerves;  novocain  and  eucain  are  most  used  for  this  purpose. 

General  Anesthesia. — The  patient  should  have  his  bowels  well 
opened  the  day  previously,  and  should  have  eaten  no  food  for  at  least 
eight  hours  before  the  anesthetic  is  administered,  as  all  general  anes- 
thetics, especially  ether,  produce  some  degree  of  nausea.  In  opera- 
tions not  involving  the  stomach  or  intestines,  there  is  no  objection 
to  the  patient  drinking  a  glass  of  hot  water  half  an  hour  before  the 
operation.  This  prevents  gastric  irritation  from  any  of  the  anesthetic 
unavoidably  swallowed.  Before  giving  an  anesthetic,  a  thorough 
physical  examination  of  the  heart  and  lungs  should  be  made,  and  the 
patient  should  remove  false  teeth,  chewing  gum,  tobacco,  etc.,  from  the 
mouth,  as  well  as  hairpins,  earrings,  etc.  Many  surgeons  have  the  habit 
of  giving  a  hypodermic  injection  of  morphin  half  an  hour  before  com- 
mencing the  anesthetic;  in  some  cases  it  is  valuable,  but  in  others 
apart  from  being  a  pure  waste  of  a  valuable  drug,  it  is  actually  harm- 
ful. The  clothes  should  be  loosened  around  the  throat  and  so  dis- 
posed as  to  make  artificial  respiration  easy  in  case  of  emergency. 
During  anesthetization  and  while  recovering  from  the  effects  of  anes- 
thetics, the  chests  and  shoulders  of  patients  should  be  carefully 
covered,  as  they  are  very  prone  to  catch  cold.  No  anesthetic  should 
be  administered  in  the  dark;  change  of  color  frequently  is  one  of  the 
most  easily  recognized  signs  of  danger,  and  unless  the  patient  is  being 
anesthetized  in  a  good  light  this  cannot  be  appreciated.  The  fre- 
quency of  ether  deaths  in  negroes  is  probably  due  to  inability  to 
recognize  cyanosis  readily  in  them.  The  patient  should  be  supine, 
with  the  head  comfortably  supported,  especially  in  the  old  and  round- 
shouldered,  in  asthmatics,  etc.  Throughout  the  course  of  anestheti- 
zation the  anesthetizer  must  pay  strict  attention  to  his  own  duties, 
and  neither  attempt  to  follow-  the  minute  details  of  the  operation  nor 
to  converse  on  irrelevant  topics  with  bystanders.  He  is  responsible 
for  the  life  of  the  patient  quite  as  much  as  the  surgeon;  and  it  is  a 
sad  fact  that  the  disproportionate  number  of  deaths  from  anesthesia 
which  occur  during  trivial  operations  is  usually  due  to  carelessness 
of  the  anesthetist.  With  an  ear  for  respirations,  a  finger  on  the  tem- 
poral pulse,  and  an  eye  on  the  patient's  pupils,  the  anesthetist  need 
not  fear  to  have  his  attention  wander  or  to  meet  with  unforeseen 
accidents. 

Ether1  is  the  safest  general  anesthetic  for  major  surgery,  and  probably 
is  the  most  widely  employed.  Hewitt  places  its  death  rate  at  1  in 
16,000,  five  times  safer  than  chloroform,  though  slightly  less  safe  than 

'Commercial  ether  contains  many  impurities,  and  J.  H.  Cotton  (1917)  claims 
that  its  anesthetic  properties  are  due  to  some  of  the  impurities,  while  others  are 
responsible  for  its  unpleasant  after-effects.  By  administration  of  chemically 
pure  ether  to  which  have  been  added  only  the  impurities  which  produce  anesthesia, 
he  claims  to  have  obtained  abolition  of  sensation  without  loss  of  consciousness. 


ANESTHESIA  AND  ANESTHETICS 


151 


nitrous  oxide.  Ether  (ethyl  oxide)  is  a  heavy,  highly  inflammable 
liquid  of  strong  pungent  odor.  Its  vapor  is  heavier  than  air,  and 
sinks  to  the  floor;  hence  all  lights  should  be  kept  high  above  the 
operating  table,  as  occasionally  patients  have  been  seriously  burned 
by  ignition  of  ether  fumes.  I  prefer  to  administer  it  by  the  so-called 
"open,   drop-method,"   as   follows: 

The  patient's  cheeks,  nose,  and  lips  may  be  greased  with  vaselin 
to  prevent  the  rubefacient  effect  of  the  ether.  Place  eight  to  twelve 
layers  of  dry  wide-meshed  gauze  across  the  patient's  mouth  and  nose, 
and  ask  him  if  he  can  breathe  through  the  gauze.  He  always  answers 
"yes."  Then  directing  him  to  shut  his  eyes  and  mouth,  and  to  breathe 
through  his  nose,  hold  the  gauze  lightly  in  place,  but  do  not  exclude 
all  the  air  from  under  its  edges;  drop  the  ether  gently  over  the  gauze, 
one  drop  every  second  or  so,  moistening  an  area  an  inch  and  a  half  in 
diameter  just  below  the  tip  of  the  nose  (Fig.  101).  When  given  thus 
slowly  very  little  if  any  respiratory  irritation  is  produced,  the  patient 
continues  to  breathe  in  his  natural  way,  and  by  the  time  50  to  00  c.c. 


Fig.  101. — Etherization  by  the  open,  drop-method.     Episcopal  Hospital. 

have  been  administered  he  is  usually  unconscious,  not  having  exhibited 
any  "stage  of  excitement."  The  lower  jaw  should  be  constantly  held 
forward  by  the  fingers  placed  back  of  the  angle,  on  the  ramus,  as 
anesthesia  paralyzes  the  muscles,  and  unless  supported  the  jaw  may 
fall  backward  and  allow  the  base  of  the  tongue  to  force  the  epiglottis 
over  the  larynx.  When  the  respirations  become  mechanical,  like 
those  of  sleep,  the  pupils  are  found  contracted  but  still  reacting  to 
light  and  the  conjunctival  reflexes  are  abolished;  then,  after  a  little 
more  ether  is  administered  muscular  relaxation  becomes  complete.  The 
time  consumed  is  usually  from  ten  to  fifteen  minutes.  The  operation 
may  then  be  commenced.1  The  time  may  be  shortened  by  excluding 
air  more  completely:  this  is  easily  accomplished  by  keeping  the  margins 

1  Many  very  short  operations  (half  a  minute)  may  be  done  during  the  stage 
known  as  "primary  anesthesia,"  described  many  years  ago  by  Packard.  The 
patient  is  directed  to  hold  one  arm  aloft,  when  inhalations  are  begun,  and  to  hold 
it  up  as  long  as  possible.  The  moment  the  arm  drops  is  the  opportune  time  for 
surgical  intervention.  In  Germany  this  state  of  first  insensibility  from  the 
anesthetic  is  known  as  the  "Ether  Rausch." 


L52  si  RG1CAL   TECHNIQUE 

of  the  gauze  in  contact  with  the  patient's  face,  and  by  adding  more 
dr\  gauze  mi  top  and  using  it  as  a  roof  under  which  to  drop  the  ether. 
This  concentrates  the  ether  vapor,  and  requires  less  ether;  but  unless 
cautiously  and  gradually  done  is  apt  to  cause  choking.  The  anesthe- 
tist should  never  give  enough  ether  to  cause  the  pupils  to  dilate4;  if  they 
are  kept  contracted,  but  reacting  to  light,  the  patient  is  in  the  proper 
state  tor  operation.  Frequently  during  the  course  of  an  operation  it 
may  be  possible  to  let  the  patient  come  so  far  from  under  the  influence 
of  ether  as  to  allow  his  pupils  to  return  to  their  normal  dilated  state, 
which  should  not  be  mistaken  for  the  dilated  state,  without  reaction 
to  light,  present  in  advanced  ether  poisoning.  Home  operators  prefer 
and  others  will  not  allow  the  anesthetist  to  let  the  patient  "come 
to"  from  time  to  time.  Such  idiosyncrasies  must  be  learned  by 
experience. 

In  giving  ether  to  children,  who  are  not  reasonable  enough  to  lie  still 
and  breathe  quietly,  it  is  better  to  pour  a  teaspoonful  of  ether  at  once  on 
the  gauze,  and  hold  this  firmly  in  contact  with  the  face.  After  a  short 
struggle,  and  holding  the  breath  until  thoroughly  "out  of  breath," 
the  child  will  take  a  few  deep  inspirations,  and  by  so  doing  will  pass 
completely  under  the  influence  of  the  ether  in  a  very  much  shorter 
time  and  with  very  much  less  discomfort  and  danger  to  himself  than 
if  the  struggle  had  been  prolonged  by  attempting  to  administer  the 
ether  by  the  drop-method. 

Certain  accidents  may  occur  during  etherization:  (1)  When  ether  is 
first  administered,  the  patient  may  stop  breathing.  This  usually  is 
due  to  neglect  of  the  precaution  to  start  the  patient  breathing  through 
the  gauze  before  any  ether  is  dropped  on  it,  or  to  pouring  on  a  quantity 
of  ether  instead  of  giving  it  drop  by  drop.  It  is  treated  by  removing 
the  gauze,  allowing  the  patient  to  breathe  air,  and  then  beginning 
over  again.  ('2)  The  patient,  if  an  alcoholic,  or  if  he  has  taken  ether 
frequently  before,  may  be  unduly  exhilarated  by  the  stimulating  effect 
of  the  ether.  Hence  it  may  be  necessary  to  use  forcible  restraint, 
and  preparation  should  accordingly  be  made.  So  long  as  respiration 
is  good,  the  administration  of  more  ether  is  indicated,  as  there  are 
very  few  patients,  indeed,  Mho  do  not  succumb  to  its  influence  in  a 
short  time.  (3)  The  patient's  throat  may  fill  up  with  mucus,  making 
respiration  difficult,  and  producing  cyanosis.  This  generally  is  due 
to  too  rapid  administration  of  ether,  to  neglect  to  hold  the  jaw  forward, 
or  to  a  preexisting  bronchitis,  etc.  It  is  best  treated  by  pulling  the 
jaw  forward,  as  already  described,  thus  opening  the  larynx;  by  turning 
the  head  to  one  side,  or  letting  it  hang  over  the  edge  of  the  table,  thus 
allowing  the  secretions  to  accumulate  in  the  cheek  or  to  run  out  of 
the  mouth;  and  finally  by  the  use  of  a  mouth-gag  with  direct  removal 
of  the  mucus  by  sponging.  The  mouth-gag  is  rarely  required  by  a  good 
etherizer;  but  it  should  always  be  at  hand  for  emergencies.  Marine 
sponges  are  best  for  this  purpose;  each  should  be  about  4  cm.  in  dia- 
meter, freshly  wrung  dry  out  of  luke-warm  water,  and  fixed  firmly  in 
a  long  handle.    When  the  jaws  have  been  opened  by  the  gag,  the  tongue 


ANESTHESIA  AND  ANESTHETICS 


153 


Fig.  102. — Tongue  forceps. 


is  grasped  with  gauze  or  a  suitable  forceps  (Fig.  102),  and  pulled 
forward  and  upward.  This  alone  may  make  respiration  easier.  If 
necessary,  the  sponges  are  to  be  passed  back  into  the  pharynx,  and 
by  a  combined  sweeping  and  rotary  motion  are  made  to  collect  as 
much  mucus  as  possible.  (4)  The  patient  may  stop  breathing  from 
no  foreseen  cause.    This  fre- 

o 


quently  is  due  to  the  admin- 
istration of  too  much  ether, 
occasionally  to  reflex  inhi- 
bition from  injudicious  trac- 
tion on  the  tongue  or  spong- 
ing, and  rarely  to  the  direct 
shock  of  the  operation.     It 

is  treated  by  artificial  respiration,  by  hypodermic  stimulation,  and 
by  inhalations  of  ammonia  and  oxygen  when  once  respiration  is 
restored.  (5)  Vomiting  occurs  from  neglect  to  abstain  from  food  before 
operation,  but  will  not  occur  after  anesthesia  is  once  complete,  unless 
the  patient  is  allowed  to  come  out  of  the  anesthetic  too  far. 

Chloroform. — One  death  among  every  3749  chloroform  anesthesias 
is  attributed  to  the  action  of  the  drug.  Its  action  is  more  rapid  than 
that  of  ether,  and  the  zone  of  safety  is  much  narrower.  It  has  been 
said  that  the  danger  signals  appear  and  the  collision  occurs  at  the 
same  instant;  there  is  not  sufficient  warning,  as  there  is  in  etheriza- 
tion, for  disaster  to  be  avoided.  The  most  important  thing  in  chloro- 
form anesthesia  is  to  allow  the  mixture  of  plenty  of  air  with  the  inhaled 

vapor.  On  this  account  I 
think  the  simplest  way  to 
administer  chloroform  is  by 
dropping  it  slowly  on  one 
or  two  thicknesses  of  gauze 
stretched  over  a  wire  frame, 
made  to  fit  over  the  mouth 
and  nose  in  such  a  way  that 
the  part  of  the  gauze  moist- 
ened by  the  chloroform  is 
always  2  cm.  or  more  dis- 
tant from  the  patient's  lips  (Fig.  103).  Even  stricter  attention  to 
the  pulse  and  respiration  is  required  than  in  giving  ether;  but  a  stage 
of  excitement  scarcely  ever  occurs,  little  or  no  bronchial  irritation  is 
produced,  and  vomiting  during  recovery  from  anesthesia  is  very 
unusual. 

Ethyl  chloride  is  a  seductive  but  dangerous  anesthetic.  It  acts  as 
quickly  as,  and  even  more  pleasantly  than  chloroform. 

Nitrous  oxide,  a  gas  which  is  universally  employed  for  minor 
dental  operations,  may  be  equally  well  employed  in  surgery  for  short 
operations  where  complete  muscular  relaxation  is  not  required.  It 
exerts  its  influence  in  less  than  a  minute  and  is  the  least  unpleasant 
anesthetic  to  take.    It  acts  largely  by  causing  an  accumulation  in  the 


Fig.  103. — Chloroform  inha 


154  SURGICAL  TECHNIQUE 

blood  of  carbon  dioxide.  Special  apparatus  is  used,  including  a  tank 
containing  the  gas,  a  face  mask  with  suitable  valves  to  admit  or  exclude 
air  or  oxygen  in  conjunction  with  the  nitrous  oxide,  and  a  rubber 
bag,  inserted  between  the  tank  and  the  mask,  in  which  the  gas  collects, 
hut  from  which  the  expired  air  is  excluded  by  an  automatic  valve. 
When  a  suitable  admixture  of  oxygen  is  permitted,  skilful  anesthetists 
may  prolong  the  duration  of  anesthesia  for  several  hours.  Nitrous 
oxide  frequently  is  used  to  induce  anesthesia,  ether  or  chloroform  being 
substituted  later.  As  I  have  seen  it  used  in  this  way  I  have  not  been 
able  to  see  any  advantages  over  the  skilful  administration  of  ether 
from  the  start;  but  when  nitrous  oxide  and  oxygen  are  used  alone, 
without  any  recourse  to  ether,  recovery  from  the  anesthetic  occurs 
much  more  promptly,  and  there  are  no  unpleasant  after-effects. 

Choice  of  a  General  Anesthetic. — Unless  contraindicated,  ether  is 
to  be  preferred,  because  it  is  the  safest.  Its  greatest  danger  is  post- 
operative bronchitis  or  pneumonia;  but  with  proper  precautions  against 
exposure  of  the  patient,  and  by  giving  it  drop  by  drop,  such  com- 
plications are  not  to  be  feared.  Moreover,  it  is  better  for  a  patient 
to  be  nauseated  and  to  have  bronchial  irritation  after  recovery  from 
ether  than  for  him  to  be  killed  by  chloroform  or  ethyl  chloride.  In 
cases  where  bronchitis,  phthisis,  etc.,  exist,  or  where  the  kidneys  are 
seriously  diseased,  and  where  some  general  anesthetic  has  to  be 
employed,  nitrous  oxide  and  oxygen  should  be  preferred.  Chloroform 
is  particularly  to  be  avoided  in  cases  of  heart  lesion  not  properly 
compensated,  and  in  cases  of  shock.  Nitrous  oxide  causes  cyanosis, 
stertor,  and  muscular  regidity,  with  such  increase  of  blood  pressure 
that  it  is  especially  contraindicated  in  patients  with  arteriosclerosis; 
its  successful  administration  requires  much  more  skill  and  experience 
than  does  that  of  ether,  but  when  skilful  assistance  is  available,  and 
the  operation  will  not  consume  more  than  thirty  or  forty  minutes,  it 
is  when  combined  with  oxygen  a  safer  and  more  desirable  anesthetic 
than  is  ether  for  patients  with  visceral  lesions  other  than  those  of  the 
vascular  system.  It  is  preferable  also  in  all  septic  conditions,  as  it 
introduces  nothing  which  has  to  be  eliminated  by  the  viscera;  both 
ether  and  chloroform  are  more  or  less  toxic. 

Administration  of  General  Anesthetic  for  Special  Operations. — Head 
and  Neck. — It  is  found  often  in  operations  on  the  head  and  neck 
that  the  anesthetist  is  very  much  in  the  way,  and  that  the  progress 
of  the  operation  interferes  with  the  proper  administration  of 
the  anesthetic.  One  of  the  simplest  methods  of  overcoming  this  is 
to  have  the  ether  vapor  conducted  to  the  patient's  mouth  through 
a  tube,  so  that  the  anesthetist  may  stand  at  some  distance.  Through 
the  cork  of  the  ether  bottle  pass  two  tubes— an  afferent  tube  which  is 
connected  with  a  hand  bulb,  and  an  efferent  tube  which  is  three  or  four 
feet  long  and  leads  to  the  patient's  mouth.  If  a  hooked  metal  tube  is 
attached  at  the  mouth  end,  it  will  hang  in  the  angle  of  the  mouth  and 
keep  its  place  without  difficulty.  The  ether  vapor  has  never  caused,  in 
my  experience,  any  evidence  of  stomatitis.     If  its  irritating  effects  are 


ANESTHESIA  AND  ANESTHETICS  155 

feared,  the  vapor  may  be  conducted  by  tube  over  or  through  a 
bottle  of  water  before  entering  the  mouth.  The  patient  is  first 
anesthetized  in  the  usual  way,  and  when  thoroughly  relaxed,  the 
gauze  is  removed  from  the  face,  the  mouth  tube  introduced,  and  the 
ether  vapor  forced  into  the  mouth  by  use  of  the  hand  bulb.  If  avail- 
able a  current  of  oxygen  or  of  compressed  air  may  be  conducted 
through  the  ether  bottle,  thus  replacing  the  hand  bulb. 

Crile's  plan  is  another  convenient  method.  After  the  patient  is 
anesthetized,  the  surgeon  passes  a  well  greased  tube  through  each 
nostril  to  the  naso-pharynx,  and  packs  the  mouth  loosely  with  gauze. 
The  outer  ends  of  the  nasal  tube  are  connected  by  a  Y-shaped  glass 
tube  to  a  long  rubber  tube,  at  the  far  end  of  which  is  a  funnel  lightly 
filled  with  gauze.  The  ether  is  then  administered  by  being  dropped 
on  the  gauze  in  the  funnel.  It  is  well  to  have  a  U-tube  inserted 
somewhere  in  the  tube  which  conducts  the  ether  vapor  to  the  patient, 
so  that  in  it  may  collect  any  condensation  from  the  ether  vapor. 

Intrathoracic  Operations. — When  the  pleura  is  opened,  the  lung 
partially  collapses,  and  in  consequence  there  may  be  considerable 
respiratory  disturbance  and  interference  with  the  administration  of  an 
anesthetic.  To  overcome  this  Sauerbruch,  of  Breslau,  devised  (1904) 
a  plan  for  operating  under  negative  atmospheric  pressure,  thus  allowing 
the  lung  to  remain  expanded.  In  this  method  the  patient  is  placed 
in  a  chamber  in  which  negative  pressure  can  be  induced;  his  head 
projects  through  an  opening  in  this  chamber,  and  a  rubber  collar 
fitting  closely  around  his  neck  makes  the  aperture  air-tight.  The  anes- 
thetist sits  outside  the  chamber,  while  the  surgeon  and  his  assistants 
must  remain  inside.  This  plan  of  operating  under  negative  pressure 
entails  expensive  apparatus,  and  a  specially  constructed  operating- 
room,  which  cannot  be  moved  from  place  to  place.  Dr.  Willy  Meyer, 
of  New  York,  is  the  chief  supporter  of  the  method  in  America,  and 
has  had  a  very  complete  operating  suite  constructed  in  the  Lenox 
Hill  Hospital  in  that  city. 

Positive  Pressure  Method. — This  was  introduced  by  Brauer,  of 
Heidelberg,  very  soon  after  Sauerbruch's  method.  Here  the  patient's 
head  and  the  anesthetist  are  in  a  specially  constructed  chamber, 
in  which  the  atmospheric  pressure  may  be  increased,  by  suitable 
apparatus,  so  that  when  the  pleural  cavity  is  opened  the  lung  stays 
expanded.  This  appears  to  be  a  simpler  method  than  that  of  negative 
pressure,  and  seems  quite  as  efficient;  but  has  not  been  used  much 
in  this  country. 

Intratracheal  Insufflation. — Meltzer  and  Auer,  of  the  Rockefeller 
Institute,  New  York,  found  in  experiments  on  dogs,  in  1909,  that  if 
a  tube  was  passed  down,  the  trachea  almost  to  its  bifurcation,  and 
if  air  mixed  with  ether  was  constantly  blown  in  through  this  tube  by 
suitable  bellows,  the  dog's  lungs  remained  expanded  even  when  both 
pleurae  were  widely  opened,  that  anesthesia  could  be  maintained  for 
hours,  and  that  it  was  impossible  to  kill  the  dogs  by  an  overdose  of  the 
anesthetic.    This  method  was  adapted  for  human  beings  by  Elsberg, 


L56  SURGICAL  TECHNIQUE 

of  New  York.  Imt  in  most  operations  where  it  was  formerly  used,  it 
is  found  sufficient  to  employ  nasnl  tubes  conducting  the  ether  vapor 
only  as  Far  as  the  pharynx.  This  method  is  a  greal  convenience  in 
operations  on  the  mouth  and  pharynx,  as  it  prevents  aspiration  of 
mucus  or  blood.  Briefly  described,  the  apparatus  is  as  follows:  An 
electric  motor  is  used  to  pump  the  air  by  tube  to  the  ether  bottle, 
where  the  tubing  is  so  arranged  with  stopcocks  that  (1)  all  the  air 
may  pass  directly  on  to  the  patient  without  coming  into  contact 
with  the  ether;  (2)  all  the  air  may  pass  through  the  ether  bottle, 
and  thus  become  saturated  with  the  anesthetic  before  reaching  the 
patient;  or  (3)  some  of  the  air  may  pass  directly  on  to  the  patient 
while  some  passes  through  the  ether  bottle  before  reaching  the 
patient.  Thus  the  amount  of  ether  to  be  administered  may  be  accu- 
rately regulated.  The  ether  enters  the  ether  bottle  by  gravity,  drop 
by  drop,  from  a  container,  and  is  vaporized  by  contact  with  a  heated 
cylinder.  An  oxygen  tank  may  be  connected  with  the  tube  leading 
to  the  patient,  so  that  pure  oxygen  or  oxygen  mixed  with  air  in  any 
proportion  may  be  inhaled. 

The  tube  leading  from  the  ether  bottle  to  the  patient  is  connected 
with  a  manometer,  and  has  a  Y-ending,  one  branch  for  connection  with 
the  intratracheal  tube,  and  the  other  to  be  used  as  a  cut  out,  to  allow 
collapse  of  the  lungs  at  any  instant  desired.  The  apparatus  may  be 
obtained  now  in  very  compact  form. 

The  intratracheal  tube  should  be  fairly  rigid,  of  the  length  of  a 
stomach  tube,  and  about  half  the  diameter  of  the  trachea.  The 
patient  is  given  hypodermatically  morphin  and  atropin,  and  is  anes- 
thetized in  the  usual  manner.  The  tube  is  then  passed  through  the 
larynx  into  the  trachea.  This  is  facilitated  by  the  use  of  the  broncho- 
scope- tube  or  speculum.  When  the  intratracheal  tube  is  momentarily 
arrested  at  the  bifurcation  of  the  trachea,  it  is  withdrawn  about  3 
em.  If  the  tube  is  in  correct  position  air  will  enter  both  lungs;  if 
it  has  been  pushed  in  so  far  as  to  be  arrested  at  the  division  of  the  right 
bronchus,  no  air  will  enter  or  leave  the  left  lung.  When  in  proper  posi- 
tion, the  tube  is  clamped  just  outside  the  dental  margin  by  a  frame 
supported  on  the  ears,  resembling  a  spectacle  frame.  "The  tube  is 
now  connected  with  the  air  pressure  apparatus,  and  air  is  blown 
through  at  a  pressure  of  10  mm.  of  mercury.  After  several  minutes, 
the  pressure  is  raised  to  20  mm.  and  the  operation  can  be  begun. 
When  the  pressure  of  the  inflowing  air  and  ether  equals  20  mm.  of 
mercury,  inspiration  and  expiration  will  continue,  air  being  inhaled 
and  exhaled  by  the  side  of  the  tube.  If  there  existed  a  profuse  secre- 
tion of  mucus  in  the  pharynx  and  trachea,  this  will  be  found  to  have 
ceased  soon  after  the  insufflation  was  begun.  Every  two  to  three 
minutes,  an  assistant  opens  a  vent  so  that  the  current  of  air  which 
enters  the  tube  is  interrupted  for  a  moment."     (Elsberg.) 

No  ill  effects  have  been  noted  from  anesthesia  maintained  by  this 
method.  Far  from  favoring  pulmonary  complications,  it  seems  to 
prevent  them. 


ANESTHESIA  AND  ANESTHETICS  157 

Local  Anesthesia  may  be  secured  by  freezing  the  skin  with  a  mix- 
ture of  ice  and  salt,  or  by  a  spray  of  ethyl  chloride  or  rhigolene.  The 
skin  becomes  white,  covered  with  minute  crystals  of  ice,  and  is  rendered 
very  tough.  The  anesthesia  lasts  only  a  few  seconds,  but  sufficiently 
long  for  opening  superficial  abscesses,  etc.  If  the  patient  only  knew 
that  the  thawing  hurts  as  much  or  more  than  a  sudden  stab  with  a 
sharp  bistoury,  he  probably  would  prefer  to  have  this  form  of  local 
anesthesia  abandoned. 

Novocain  (procain)  and  eucain  are  the  chief  agents  used  for  local 
anesthesia.  They  are  now  on  the  market  in  tablet  form,  and  are 
used  in  half  strength  (0.45  per  cent.)  normal  saline  solution.  Of 
eucain,  a  1  or  2  per  cent,  solution  is  preferred;  this  is  stable,  not  toxic 
in  ordinary  amounts,  and  may  be  sterilized  repeatedly  by  boiling. 
Of  novocain  a  0.25  per  cent,  solution  is  sufficient.  Adrenalin  may 
be  added  but  it  is  not  necessary;  it  constringes  the  capillaries  and 
prevents  diffusion  of  the  anesthetic.  Where  large  quantities  are 
used,  it  is  convenient  to  prepare  the  solution  in  bulk.  To  make  0.25 
per  cent,  solution  of  novocain,  to  500  c.c.  sterile  normal  saline  solu- 
tion, add  1.25  gm.  of  novocain  crystals;  boil  for  ten  minutes  on  two 
successive  days.  To  make  1  per  cent,  eucain  solution,  add  5  gm. 
to  500  c.c.  of  saline  solution,  sterilize,  and  just  before  using  add  3 
drops  of  adrenalin  chloride  solution  (1  to  10,000)  to  every  30  c.c.  of 
the  anesthetic.  As  a  rule  15  to  30  c.c.  of  either  solution  suffices  for  a 
major  operation. 

Cocain,  on  account  of  its  toxicity,  and  because  usually  rendered  inert 
by  boiling,  is  little  used  except  for  applications  to  mucous  membranes 
(eye,  throat,  urethra,  bladder);  a  2  per  cent,  solution  may  be  used, 
and  sometimes  a  4  per  cent,  solution.  It  is  dropped  on  the  surface  of 
the  eye,  and  is  applied  to  the  nose  and  throat  by  a  pledget  of  absorbent 
cotton;  while  it  is  injected  into  the  urethra  and  bladder  by  means 
of  the  urethral  syringe,  catheter,  or  instillator. 

Hypodermic  Use. — The  skin  is  pinched  up  as  in  giving  a  hypodermic 
injection,  but  the  needle,  which  enters  at  one  end  of  the  proposed 
incision,  with  its  point  directed  toward  the  other  end,  is  not  passed 
into  the  subcutaneous  tissues,  but  its  point  is  arrested  in  the  true  skin, 
the  first  injection  being  endodermic,  not  hypodermic.  As  the  piston 
of  the  syringe  is  pushed  down,  a  distinct  wheal  is  raised  in  the 
skin;  the  needle  is  then  pushed  on  within  the  true  skin  until  its 
point  reaches  the  limit  of  the  wheal,  when  another  wheal  is  pro- 
duced, and  so  on  until  the  entire  length  of  the  needle  has  entered. 
It  is  then  withdrawn  and  reintroduced  at  the  furthest  point  reached, 
and  the  process  is  repeated  until  the  line  of  the  entire  incision  has 
been  anesthetized.  An  incision  may  then  be  made  through  the  skin, 
and,  with  a  few  added  drops  here  and  there  as  required,  this  degree  of 
anesthesia  will  suffice  for  circumcision,  removal  of  sebaceous  cysts  and 
small  tumors,  opening  cold  abscesses,  etc.  When  a  more  extensive 
operation  is  undertaken,  as  one  for  hernia,  goiter,  etc.,  special  atten- 
tion  must   be   paid   to   nerves,    bloodvessels,   and   connective-tissue 


1 58 


SURGICAL   TECHNIQUE 


bundles  {infiltration  anesthesia).  Almost  any  quantity  of  the  weaker 
solutions  may  be  used,  especially  when  local  anesthesia  is  aided  by 
constriction  of  the  limb  above  the  seat  of  operation. 

Nerve  blocking  may  be  accomplished  by  perineural  or  endoneural 
injections,  the  latter  being  preferable  as  more  accurate  and  permitting 
a  wider  range  of  operative  procedure.  Certain  nerves  (ulnar,  per- 
oneal) may  be  reached  directly,  but  usually  it  is  necessary  to  bare 
the  nerve  by  the  hypodermic  use  of  novocain  as  already  described. 
In  the  endoneural  method,  the  solution  is  injected  directly  among 
the  nerve  fibers  of  the  main  trunks  conveying  sensation  from  the 
region  to  be  operated  on. 


Fig.  1U4. — Spinal  analgesia.  Needle  between  spines  of  second  and  third  lumbar 
vertebrae.      Posterior   superior  iliac   spines   marked    with   iodin.      Episcopal   Hospital. 

Spinal  anesthesia  is  closely  allied  to  nerve  blocking.  It  was  sug- 
gested in  1885  by  Leonard  Corning,  of  New  York;  was  employed  in 
1889  by  Tuffier;  and  has  been  more  widely  used  abroad  than  in  this 
country.  The  anesthetic  acts  on  the  roots  of  the  spinal  nerves,  not  on 
the  cord  itself.  The  injection  is  made  usually  in  the  second  or  third 
lumbar  interspace  (Fig.  104);  as  a  rule,  anesthesia  (which  affects  both 
motor  and  sensory  impulses,  especially  the  latter)  extends  only  to  the 
region  of  the  waist,  and  therefore  operations  best  suited  for  spinal 
anesthesia  are  those  on  the  lower  extremities  or  pelvis.  Stovain 
(4  per  cent,  solution)  usually  is  preferred  to  other  anesthetics. 
About  1.5  to  2  c.c.  are  employed.  The  anesthesia  begins  in  a  few 
minutes  and  lasts  nearly  an  hour.  As  positive  contraindications  to 
spinal  anesthesia  may  be  mentioned:  Advanced  cachexia,  bilateral 
nephritis  with  scanty  excretion,  myocarditis,  pericarditis  with  effu- 
sion, non-compensated  cardiac  disease.  Most  operations  in  which 
spinal  anesthesia  may  seem  desirable,  can  be  done  equally  well  under 
local  anesthesia. 


CHAPTER  VI. 
INJURIES  AND  THEIR  EFFECTS. 


LOCAL  EFFECTS  OF  INJURIES. 

The  local  effects  of  injury  depend  on  the  part  injured,  as  well  as 
on  the  force  exerted  by,  and  the  manner  of  action  of  the  vulnerating 
body.  A  smart  blow  with  a  rope  will  produce  a  wheal;  if  the  rope 
slips  rapidly  through  the  hands  with  violent  friction,  a  brush-burn 
will  result;  but  if  the  rope  is  twisted  tightly  around  the  part,  strangula- 
tion will  occur.  Striking  the  foot  against  a  large  stone  will  cause  a 
contusion,  but  if  the  same  stone  falls  on  the  leg  it  may  fracture  the 
bones.  Injury  of  parts  with  abundant  and  lax  subcutaneous  tissues 
will  be  attended  by  much  greater  swelling  than  where  these  tissues 
are  firm  and  resistant;  injuries  of  certain 
parts  are  much  more  dangerous  than 
similar  or  severer  injury  expended  upon 
other  parts  not  so  highly  specialized  or  so 
vascular. 

The  local  effects  of  heat,  cold,  etc.,  are 
considered  at  p.  176. 

Abrasions. — An  abrasion  is  an  injury  in 
which  merely  the  epiderm  has  been  re- 
moved by  slight  friction;  brush-burns, 
produced  by  violent  friction,  resemble 
contused  wounds  (p.  166).  An  excoriation 
is  an  injury  produced  by  scratching  or 
scraping  which  involves  the  corium.  The 
resulting  ulcers  heal  readily  when  properly 
protected. 

Contusions. — A  contusion  is  a  subcuta- 
neous injury  of  the  soft  parts  produced  by 
blunt  force  (kicks,  falls,  etc.).  There  is  al- 
ways a  certain  amount  of  blood  extravasated 
among  the  lacerated  tissues;  when  this 
blood  is  visible  in  moderate  amount  be- 
neath the  skin,  it  is  termed  an  ecchymosis 
(Fig.  318,  p.  332);  and  as  it  undergoes  ab- 
sorption it  passes  through  various  shades  of  purple,  green,  black,  and 
blue.  A  very  minute  ecchymosis  is  called  a  petechia.  Blood  extravas- 
ated beneath  the  conjunctiva  remains  bright  red  a  long  time,  owing 
to  oxidation  through  the  thin  overlying  tissues.  When  enough  blood  is 
extravasated  to  cause  an  appreciable  collection  of  fluid,  it  is  called  a 

(159) 


Fig.  105. — Hematoma  of  left 
thigh  ten  days  after  a  fall ;  also 
fracture  of  shaft  of  left  hu- 
merus. Age  forty-eight  years. 
Episcopal  Hospital. 


1G0  INJURIES  AND   THEIR  EFFECTS 

hematoma;  or  if  clotted  a  thrombus.  The  skin  itself,  though  more 
resistant  than  the  subcutaneous  tissues,  does  not  always  escape 
injury  in  a  contusion;  such  injury  is  manifested  in  the  course  of 
twelve  to  twenty-four  hours  by  vesicles,  blisters,  and  bulla?.  These 
usually  appear  before  the  ecchymoses,  which  rarely  become  apparent 
until  the  second  or  third  day.  The  diagnosis  of  a  contusion  is  easy, 
being  based  on  the  history  of  injury  by  blunt  force;  on  the  indentation 
of  the  soft  parts  (especially  on  the  scalp),  often  persisting  when  the 
patient  is  seen  soon  after  the  accident;  on  the  local  tenderness  which 
is  rapidly  followed  by  swelling,  extravasation,  and  ecchymosis.  The 
prognosis  is  good,  unless  there  is  some  undetected  injury  to  nerves, 
bloodvessels,  bones,  joints,  or  internal  organs.  The  hematoma  which 
forms  seldom  causes  anxiety;  usually  the  bleeding  ceases  spon- 
taneously, or  under  the  application  of  cold,  elevation  of  the  part, 
moderate  pressure,  etc.  The  treatment  consists  in  securing  local  rest, 
in  applying  anodyne  or  slightly  stimulating  fomentations  (arnica, 
dilute  alcohol,  ichthyol  ointment),  and  in  promoting  absorption  of 
the  hematoma  at  a  later  date  by  gentle  massage,  firm  bandaging, 
etc.     Constitutional  treatment  is  rarely  required. 

Strangulation. — Strangulation  of  a  part  results  from  the  inter- 
ruption of  the  circulation  by  the  application  of  circular  constriction 
so  tight  and  sufficiently  long  as  to  cause  passive  changes  somewhat 
resembling  those  seen  in  contusion.  If  the  strangulation  is  not 
relieved  (by  elevation,  by  division  of  constricting  bands,  etc.),  the 
part  dies,  and  is  removed  as  a  slough  by  granulations  at  the  point  of 
constriction.  All  the  dangers  from  infection,  present  in  gangrene 
from  other  causes,  arise,  and  life  is  occasionally  lost. 

Wounds. — A  wound  is  a  solution  of  continuity  of  the  soft  tissues 
the  result  of  violence.  A  wound  is  open  if  the  skin  is  as  widely  divided 
as  the  underlying  structures;  or  subcutaneous  if  the  division  of  the 
skin  is  insignificant.  Wounds  are  also  described  as  incised,  lacerated, 
contused,  punctured,  or  poisoned.  Gunshot  wounds,  which  resemble 
contused  wounds,  are  considered  in  Chapter  VII. 

Incised  Wounds. — Incised  wounds,  which  may  be  regarded  as  the 
normal  type,  are  those  made  by  clean  cuts  wTith  sharp  instruments, 
and  are  produced  by  the  surgeon  in  every  cutting  operation.  Most 
accidental  wounds  partake  more  of  the  nature  of  lacerated  than 
incised  wounds,  as  the  instruments  by  which  they  are  inflicted  (pocket 
knives,  broken  glass,  axes,  etc.),  are  not  as  sharp  as  surgical  instru- 
ments, and  even  if  sharp  (as  razors)  are  not  wielded  with  the  delicacy 
and  precision  necessary  in  surgery.  Pain,  hemorrhage,  and  gaping 
are  the  main  symptoms  of  incised  wounds.  The  pain  varies  with 
the  size  of  the  wound,  with  the  sensibility  of  the  part  wounded,  and 
with  the  manner  in  which  the  wound  is  produced.  A  large  wound 
hurts  more  than  a  small  one;  wounds  of  the  face  and  hands  hurt 
more  than  those  of  the  back  and  buttocks  where  the  cutaneous  nerves 
are  less  developed;  and  a  quickly  made  incision  causes  less  pain 
than  one  which  is  bungled.    The  hemorrhage  depends  largely  on  the 


INCISED  WOUNDS  161 

location  of  the  wound,  and  on  the  implication  of  large  vessels.  Wounds 
of  the  face  and  scalp  bleed  profusely,  because  of  the  vascularity  of 
these  parts,  and  because  in  the  scalp  the  vessels  cannot  contract 
and  retract.  The  gaping  of  a  wound  depends  on  the  natural  elasticity 
of  the  tissues  divided.  A  wound  which  runs  in  the  direction  of  the 
natural  folds  of  the  skin  will  gape  less  than  one  which  crosses  these 
folds;  one  which  divides  muscles  transversely  will  gape  widely;  the 
divided  ends  of  tendons,  arteries,  and  nerves  may  retract  for  several 
centimeters  from  the  point  of  division. 

Process  of  Healing  in  Incised  Wounds. — As  the  result  of  the  irrita- 
tion produced  by  the  vulnerating  body,  tissue  changes  occur  which 
are  pathologically  identical  with  those  seen  in  the  process  of  inflam- 
mation; so  that  the  healing  of  an  incised  wound  is  the  same  as  Repair 
after  Inflammation  (p.  29).  It  is  convenient  to  recognize  different 
ways  in  which  union  occurs  after  a  wound  has  been  inflicted,  although 
the  difference  is  purely  quantitative,  depending  on  the  extent  of 
reaction  necessitated,  and  though  the  processes,  so  far  as  they  extend, 
are  identical  in  all  cases.  Historically,  three  ways  of  union  are  recog- 
nized: (1)  By  immediate  union  (to  which  the  term  "first  intention" 
as  used  by  Hunter  (1784)1  is  correctly  applied);  (2)  by  adhesion,  as 
understood  by  Paget  (1853);  and  (3)  by  granulation,  or  by  second 
intention. 

1.  Immediate  Union. — If  the  edges  of  an  aseptic  incised  wound 
are  accurately  apposed  so  that  each  tissue  meets  its  corresponding 
structure  in  the  other  lip  of  the  wound;  and  if  no  foreign  particles, 
even  if  aseptic,  or  no  blood-clots,  remain  between  the  lips  of  the 
wound,  then  the  reactive  process  may  extend  only  to  the  stage 
described  as  that  of  "temporary  hypertrophy."  Xo  inflammatory 
lymph  exudes,  no  granulation  tissue  forms,  and  the  wound  heals 
by  immediate  union,  or  by  the  first  intention  in  the  Hunterian  sense. 
Very  few  incisions  and  yet  fewer  wounds  heal  by  immediate  union; 
very  small  wounds  of  extremely  vascular  parts  (fingers,  face),  may 
occasionally  heal  without  the  process  of  reaction  having  extended 
beyond  the  stage  of  temporary  hypertrophy.  Such  wounds  when 
healed  leave  no  visible  scar — the  tissues  have  undergone  complete 
regeneration,  restitutio  ad  integrum. 

2.  Union  by  Adhesion. — When  the  insult  to  the  tissues  has  been 
greater,  or  when  the  tissues  themselves  have  been  less  able  to  repair 
the  damage,  the  process  of  reaction  extends  to  the  stage  of  lymph 
formation.  The  lips  of  the  wound  must  be  in  accurate  apposition, 
leaving  no  dead  spaces,  so  that  the  effused  inflammatory  lymph 
serves  as  a  framework  in  which  fibroblasts  and  granulation  tissue 
develop,  as  described  at  p.  30.  It  is  this  form  of  union  which  occurs 
in  the  vast  majority  of  aseptic  operative  incisions,  and  which  is  com- 
monly spoken  of  as  "union  by  the  first  intention,"  though  strictly 
speaking  this  term  should  be  reserved  for  immediate  union;  but  as 

1  It  is  the  "first  intention"  of  nature  to  heal  wounds  in  this  way. 
11 


162  INJURIES   AND    THEIR   EFFECTS 

for  at  least  seventy  years  it  has  been  erroneously  applied  by  the 
majority  of  surgeons,  it  is  perhaps  useless  to  register  a  protest  now. 
In  the  process  of  union  by  adhesion  a  sear  is  always  produced  extend- 
ing to  the  depths  of  the  ineision,  but  is  least  conspicuous  in  wounds 
made  with  the  greatest  precision  and  attended  by  the  least  trauma; 
so  that  the  kind  of  sears  left  by  a  surgeon  in  operating  often  give  an 
idea  as  to  the  delicacy  and  neatness  of  his  operative  methods. 

3.  Union  by  (Iran illation. — This  form  of  union,  also  known  as 
union  by  the  second  intention,  is  that  which  occurs  when  the  reaction- 
ary process  extends  to  the  stage  of  pyogenesis.  As  already  pointed 
out  (p.  27),  it  is  theoretically  possible  for  pus  to  be  formed  without 
the  intervention  of  microorganisms;  and  it  is  likewise  theoretically 
possible  for  wounds  to  unite  by  granulation  without  the  formation 
of  any  visible  pus:  but  for  either  of  these  events  to  occur  in  practice 
is  excessively  rare.  If  the  lips  of  the  wound  are  not  brought  into 
accurate  apposition,  the  gaping  surfaces  become  covered  with  visible 
granulations,  and  always,  I  believe,  some  pus  will  be  seen  on  the 
surface  of  the  healing  wound,  or  will  be  absorbed  by  the  dressings. 
The  process  of  cicatrization  and  contraction  is  pathologically  identical 
with  that  seen  in  the  healing  of  ulcers  (p.  52).  Union  by  secondary 
adhesion  (the  third  intention)  is  that  which  occurs  when  two  lips  of 
a  granulating  wound  are  apposed  by  sutures,  or  in  other  ways,  so  that 
the  fibroblasts  and  granulations  on  one  lip  grow  across  the  obliterated 
gap  into  the  granulation  tissue  on  the  opposite  lip,  thus  hastening  the 
process  of  repair.  If  there  is  much  discharge  from  the  wound  such 
secondary  adhesion  will  not  occur.  Healing  by  scabbing,  by  incrus- 
tation, or  by  subscrustaceous  cicatrization,  is  that  form  of  union  (by 
adhesion  or  by  granulation)  which  occurs  under  a  scab  formed  of 
effused  blood  and  lymph  mixed  with  the  dust,  etc.,  which  collects  on 
the  surface. 

Treatment  of  Incised  Wounds. — The  first  effort  must  be  to  check 
hemorrhage  and  to  prevent  infection.  In  operating,  aseptic  or  anti- 
septic principles  will  be  strictly  adhered  to,  and  in  wounds  accidentally 
received  the  surgeon,  after  adopting  the  necessary  measures  for 
arresting  hemorrhage  (Chapter  X)  will  employ  such  methods  of 
cleansing  the  wound  and  the  surrounding  parts  as  have  already  been 
advised  in  Chapter  V  (p.  142).  Very  small  wounds  will  gape  so  little 
that  the  proper  use  of  plasters,  compresses,  bandages,  etc.,  will  keep 
the  edges  in  contact.  In  most  wounds,  however,  the  edges  must  be 
united  by  sutures. 

Sutures  are  made  of  absorbable  or  of  non-absorbable  material. 
Absorbable  sutures  are  usually  made  of  catgut,  which  may  be  pre- 
pared in  such  a  way  that  it  will  last  a  more  or  less  definite  time  in 
the  tissues  before  being  absorbed  (10-,  20-,  and  40-day  chromicized 
catgut).  Non-absorbable  sutures  are  made  of  linen,  silk,  silkworm 
gut,  silver  wire,  etc.  Interrupted  sutures  are  shown  in  Fig.  106,  each 
separate  stitch  being  independent  of  every  other  stitch.  Varieties 
of  the  interrupted  suture  are  the  twisted,  or  hare-lip  suture  (p.  683), 


METHODS  OF  SUTURE 


163 


and  the  quilled  suture  (Fig.  107).  Continuous  sutures  are  those  in 
which  several  or  all  of  the  individual  stitches  are  made  by  one  thread 
which  is  knotted  only  at  the  beginning  and  end  of  the  line  of  suture. 
Various  forms  of  continuous  suture  are  used  in  surgery;  the  overhand 
suture  (Fig.  108)  is  most  frequently  used,  and  is  well  adapted  for 
uniting  edges  of  fascia,  skin,  etc.,  on  which  there  is  not  much  tension; 


jPHHH 


Fig.  100. — Interrupted  sutures;  each 
stitch  is  knotted  separately. 


Fig.  107. — Quilled  sutures;  each  stitch 
is  double  and  tied  over  a  quill,  or  prefer- 
ably a  rubber  tube,  which  prevents  the 
stitches  from  cutting.  Useful  when  there 
is  much  tension  on  the  sutures. 


Fig.  108. — Continuous  (overhand)  suture. 


Fig.  109. — Chain  or  lock-stitch. 


Fig.  110. — Quilt  or  mattress  suture. 


Fig.  111. — Sutures  used  to  repair  a  deep 
wound:  A,  superficial  suture  (through  the 
skin  only) ;  B,  deep  suture  (passing  deeply 
into  the  wound,  but  not  a  buried  suture) ; 
c,  c,  buried  sutures  (to  unite  peritoneum, 
deep  fascia,  etc.). 


Fig.  112. — Figure-of-eight  suture,  em- 
ployed to  unite  parietal  peritoneum,  deep 
fascia  and  skin. 


the  chain  or  lockstitch  (Fig.  109)  is  useful  where  tension  is  greater; 
while  the  quilt  or  mattress  suture  (Fig.  110),  by  passing  deeply  into 
the  tissues,  is  useful  where  there  is  tension  on  the  deeper  parts,  as 
it  tends  to  evert  the  lips  of  the  wound.  Other  forms  of  continuous 
suture  are  used  in  intestinal  surgery  (Chapter  XXII).  A  suture  may 
be  superficial,  deep,  or  buried,  as  shown  in  Fig.  111.  As  a  rule  only 
absorbable  material  should  be  used  for  buried  sutures.    Deep  sutures, 


164 


INJURIES  AND   THEIR  EFFECTS 


also  called  mass  sutures  or  splint  sutures,  are  used  to  relieve  tension 
(relaxation  sutures),  and  to  obliterate  dead  spaces  in  the  depths  of  a 
wound  in  which  it  is  not  desirable  to  leave  buried  sutures;  they  must 
be  strong  and  therefore  are  usually  of  non-absorbable  material. 
The  figure-of-eight  suture  (Fig.  112)  is  employed  by  some  surgeons 
as  a  deep  suture. 

Needles.     Straight  needles  are  most  generally  useful,  except  for 
inserting  buried  sutures,  for  which  curved  needles  are  to  be  preferred. 

Curved  needles  usually  are  held  in  a 
needle-holder  (Fig.  113),  but  straight 
needles  are  easily  managed  in  the 
fingers.  Ordinary  surgical  needles  are 
made  with  a  triangular  or  a  lance-shaped 

•   A 


A  B 


Fig.  113. — A  convenient   form  of 
needle-holder. 


J) 


Fig.  111. — Various  forms  of  needles.  A, 
straight  round-pointed  needle.  B,  straight 
lance-pointed  needle.  C,  curved  round-pointed 
needle.      D,  curved  lance-pointed   needle. 


point,  to  facilitate  their  introduction;  but  round  needles  (either  straight 
or  curved)  are  used  in  intestinal  work,  as  less  liable  to  cause  hemor- 
rhage or  to  allow  fecal  leakage  through  the  puncture  (Fig.  114).  The 
eye  of  a  needle  should  be  large  enough  to  be  threaded  easily  with  the 
suture  desired;  and  the  widest  part  of  the  needle  (belly)  should  be 


Fig.  115.- 


-1.  Reverdin's  needle,  showing  at  a  eye  opened,  at  b  eye  closed. 
2.  Ordinary  mounted  needle. 


situated  where  the  cutting  edges  ceases,  not  on  the  shaft  or  at  the  eye 
itself.  Special  forms  of  needles  are  set  in  handles,  and  have  the  eye 
near  the  point:  the  aneurysm  needle  (p.  263)  has  a  blunt  point,  and 
is  used  to  pass  ligatures  around  large  vessels;  the  ordinary  mounted 
needle  has  been  modified  by  Reverdin  by  inserting  a  slide  by  which  the 


SUTURES  AND  KNOTS 


165 


eye  may  be  opened  to  facilitate  threading  (Fig.  115),  and  is  useful 
in  passing  deep  sutures. 

Suture  of  Wounds. — Superficial  wounds  may  be  united  with  super- 
ficial sutures  only;  if  the  deep  fascia  is  divided,  it  should  be  united 
with  either  deep  or  buried  sutures,  as  the  subsequent  strength  of 
the  part  depends  largely  upon  the  accuracy  with  which  this  structure 
is  sutured,  and  even  in  parts  where  strength  is  not  requisite  (as  in 

the  neck)  neglect  to  suture  the 
deeper  layers  carefully  results 
in  a  spreading  instead  of  a 
linear  cicatrix.  Divided  tendons, 
nerves,  etc.,  should  be  sutured 
separately  by  buried  sutures. 
In  extensive  wounds,  especially 
where  the  tissues  have  been 
much  bruised,  either  by  the  in- 
jury or  during  the  operation, 
it  usually  is  desirable  to  pro- 
vide for  drainage,  to  allow  the 


Fig.  116. — The  square  or  reef  knot,  uni- 
versally employed.  Note  that  correspond- 
ing ends  of  the  ligature  pass  under  (or 
over)  the  loop  of  the  knot. 


Fig.  117. — The  surgeon's  knot;  em- 
ployed rarely,  but  useful  if  the  first  hitch 
of  the  knot  tends  to  slip  before  the  second 
can  be  pulled  tight.  The  same  as  the 
square  knot  except  that  the  first  hitch  is 
double. 


Fig.  118. — The  granny  knot.  Note  that 
of  corresponding  ends  of  the  ligature  one 
passes  over  and  the  other  under  the  loop 
of  the  knot. 


Fig.  119. — The  subcuticular  suture; 
it  may  be  used  if  no  dead  spaces  are  left 
in  the  deeper  parts  of  the  wound.  The 
needle  enters  the  true  skin  at  each  bite, 
not  merely  the  subcutaneous  tissues. 


escape  of  effused  blood,  lymph,  etc.,  which  would  retard  healing  if 
allowed  to  remain  between  the  lips  of  the  wound,  and  perhaps 
cause  sloughing  from  pressure  if  not  evacuated.  Hence  the  im- 
portance of  accurate  hemostasis  in  all  wounds,  especially  where 
drainage  is  undesirable  (as  in  operations  for  radical  cure  of  hernia). 
No  dead  spaces  should  be  left  in  repairing  wounds:  they  will  be  filled 
bv  blood-clot,  and  this  will  be  a  suitable  culture  medium  for  germs. 


166  INJURIES  AND   THEIR  EFFECTS 

• 

Sutures  must  be  drawn  just  tight  enough  to  appose  the  edges  of 
the  wound  without  constricting  the  tissues.  Drawing  a  suture  too 
tight  may  break  it,  or  may  cause  sloughing  with  a  resulting  stitch 
sinus.  Sutures  are  secured  in  position  by  knots,  or  occasionally  by 
clamping  them  with  perforated  shot.  The  knot  employed  should 
be  one  that  will  not  slip,  especially  the  square  or  reef  knot  (Fig.  116), 
or  the  surgeon's  knot  (Fig.  117),  never  the  granny  knot  (Fig.  118). 
Some  surgeons  employ  little  metal  clamps  (Michel)  to  appose  the 
skin  margins,  instead  of  sutures;  or  a  .subcuticular  suture  may  be 
use. I  (Fig-  HID. 

Dressing  of  Incised  Wounds. — On  the  surface  of  nearly  every 
wound  there  will  be  a  slight  exudation  of  serum  between  the  sutures. 
Aseptic  wounds  may  be  dressed  with  aseptic  gauze,  applied  smoothly 
and  in  sufficient  thickness  and  width  to  protect  the  part  mechanically 
and  effectually  to  prevent  the  access  of  any  microbes  from  the  sur- 
rounding skin  or  from  the  fingers  of  the  patient  accidentally  inserted 
beneath  the  edges  of  the  dressing.  This  dressing  is  then  held  in 
place  by  strips  of  adhesive  plaster,  with  suitable  bandages,  splints, 
etc.,  as  required.  If  a  tube  or  a  wick  of  gauze  has  been  employed  for 
drainage,  the  dressings  are  to  be  so  arranged  that  the  discharges 
will  be  conducted  into  the  dressings  without  soiling  the  surface  of 
the  wound;  this  is  accomplished  by  carrying  the  drain  through  slits 
in  the  dressing,  and  surrounding  its  outer  end  with  sufficient  crumpled 
gauze  to  absorb  the  anticipated  discharge;  and  carefully  protecting 
this  superficial  dressing  from  infection  by  sterile  absorbent  cotton 
or  more  gauze,  the  entire  dressing  being  suitably  bandaged  in  place. 
In  aseptic  incised  wounds  the  drain,  along  with  the  superficial  dressing, 
may  be  removed  at  the  end  of  twenty-four  or  forty-eight  hours, 
without  disturbing  the  deep  dressing.  In  infected  wounds  the  drains 
must  remain  until  their  tract  is  lined  with  granulations  (four  to  six 
days)  converting  it  into  a  sinus,  wrhich  is  to  be  treated  according 
to  the  principles  already  discussed  (p.  52)  if  it  does  not  close  spon- 
taneously. Non-absorbable  sutures  are  to  be  removed  from  the 
eighth  to  the  twelfth  day,  and  in  the  case  of  aseptic  incised  wounds  the 
dressing  need  not  be  changed  until  this  time  has  elapsed.  In  small 
wounds  of  the  face  superficial  sutures  occasionally  may  be  removed 
as  early  as  the  fourth  day,  but  in  the  case  of  a  larger  wound,  and 
especially  in  the  case  of  deep  or  relaxation  sutures,  it  is  unsafe  to 
remove  them  in  less  than  a  week  or  ten  days.  If  a  suture  is  found 
at  the  first  dressing  to  be  cutting  out,  it  should  be  removed,  trusting 
to  the  neighboring  stitches  to  maintain  the  lips  of  the  wound  in 
apposition;  and  frequently  it  is  safer  to  remove  only  alternate  stitches 
at  the  first  dressing,  and  leave  the  others  a  day  or  so  longer,  and  to 
support  the  wround  with  strips  of  sterile  adhesive  plaster  applied  at 
right  angles  to  its  surface. 

Lacerated  and  Contused  Wounds. — Lacerated  and  contused  wounds 
may  be  considered  together,  as  they  are  produced  by  the  same  acci- 
dents, and  usually  coexist.      In  lacerated  wounds  the  edges  are  torn, 


LACERATED   WOUNDS 


167 


jagged,  and  irregular,  not  sharply  cut  as  in  the  ease  of  incised  wounds; 
in  contused  wounds  the  lips  of  the  wound  and  the  surrounding  parts 
are  bruised  and  more  or  less  devitalized  by  the  original  injury.  Blows 
by  blunt  weapons  (clubs,  stones,  etc.),  and  machinery  and  railroad 
accidents  are  the  principal  causes  of  contused  and  lacerated  wounds; 
owing  to  the  manner  of  their  production  they  are  almost  invariably 
infected,  from  bacteria  on  the  patient's  skin,  his  clothing,  or  on  the 
vulnerating  weapon.  Earth,  machine  oil,  cinders,  and  other  foreign 
matter  frequently  are  carried  into  the  depths  of  the  wound.  Gunshot 
wounds,  forming  a  special  variety  of  contused  wounds  are  considered 
in  Chapter  VII. 

Symptoms. — The  pain  of  contused  and  lacerated  wounds  is  less  sharp 
and  more  aching  than  in  the  case  of  incised  wounds;  hemorrhage  is 
less,  because  the  vessels  are  twisted  and  torn  off  rather  than 
cleanly  severed;  and  gaping  is  often  much  less  than  the  extent  of 
the  injury  would  lead  one  to  expect.  Shock  is  often  severe,  and  in 
case  of  crush  or  avul- 
sion of  a  limb  may  cause 
death  so  soon  that  no  time 
is  afforded  for  local  reac- 
tion. This  reaction  in  the 
wounded  parts  frequently 
extends  to  the  stage  of  sup- 
puration, and  the  tissues 
are  so  much  devitalized 
that  more  or  less  sloughing 
is  the  rule. 

Treatment. — In  addition 
to  combating  shock  and 
checking  hemorrhage,  the 
surgeon  must  pay  particu- 
lar attention  to  cleansing 
the  wound.  Some  of  these 
injuries  are  so  severe  that 
nothing  less  than  amputa- 
tion will  save  life  (p.  212). 
But  in  lacerated  wounds 
or  crushes  of  the  hands, 
much  may  be  done  without 
amputation,  by  excision  of 

pulpefied  tissue  and  splinters  of  bone,  and  by  accurate  suture  of 
divided  tendons,  etc.  (Figs.  120,  121).  Occasionally  a  completely 
severed  finger  tip  will  grow  in  place  if  carefully  sutured.  General 
anesthesia  usually  is  indicated  to  allow  the  necessary  treatment  to  be 
carried  out.  The  object  should  be  to  make  the  wound  approach 
in  character  as  nearly  as  possible  to  an  aseptic  incised  wound.  The 
wound,  itself,  is  first  packed  with  sterile  gauze.  Then  the  surround 
ing  skin  should  be  shaved  (dry)  and  painted  with  3  per  cent,  iodin 


Fig.  120. — Compound  fracture  of  metacarpals, 
by  circular  saw  injury.  Excision  of  heads  of  meta- 
carpals, and  suture  of  tendons.   Episcopal  Hospital. 


Fig.  121. 


-Same  patient  as  Fig.  120.     Earned  nor- 
mal wages  as  carpenter. 


KiS 


INJURIES  AND   THEIR  EFFECTS 


solution.  Then  foreign  bodies  arc  to  be  removed  from  the  face  of  the 
wound,  slitting  up  (debridement,  p.  201)  pockets  and  crannies  among 
the  muscles  and  layers  of  fascia  if  necessary  to  extract  bits  of  clothing, 
coal  dusl   and  other  foreign  bodies  (epluchage,  p.  200).     The  filthy 

struct nrc-  and  parts  of  skin,  muscle,  fascia,  or  bone  that  are  entirely 
devitalized  should  be  cut  bodily  away  (excision,  p.  201).  After 
the  wound  has  been  thus  mechanically  cleansed,  it  should  be  treated 

antiseptically,  being  swabbed  out  with 
gauze  soaked  in  iodin  solution.  1  have 
entirely  abandoned  the  use  of  cor- 
rosive sublimate  and  carbolic  acid  in 
such  cases,  as  I  find  strict  adherence 
to  the  iodin  technique  secures  better 
healing.  Hydrogen  peroxide  is  an- 
other efficient  antiseptic;  it  may  be 
applied  after  the  iodin,  but  more 
than  one  thorough  application  tends 
to  delay  healing.  Menciere's  solution 
(p.  172)  is  much  used  in  France.  In  all 
cases  the  cleansing  should  be  done  with 
gentleness,  it  being  an  excellent  maxim 
of  Sir  James  Paget's  that  "wounds 
should  not  be  scrubbed,  even  with 
sponges."  In  spite  of  the  utmost 
care  it  is  not  always  possible  to  en- 
sure freedom  from  infection  in  these 
wounds,  so  it  is  alwrays  best  to  drain 
them,  using  only  sufficient  sutures 
to  hold  the  tissues  in  apposition  at 
the  extremities  of  the  wound.  Inter- 
rupted sutures  always  are  to  be  pre- 
ferred to  continuous,  in  infected 
wounds,  since  one  or  more  can  be 
removed  at  any  time  to  relieve  ten- 
sion, without  destroying  the  entire 
suture  line.  Instead  of  aseptic  gauze  it  is  better  to  use  an  antiseptic 
dressing,  especially  of  gauze  soaked  in  equal  parts  of  alcohol  and 
corrosive  sublimate.  In  extensive  wounds,  where  sloughing  is  feared, 
it  is  well  to  pour  alcohol  over  the  dressings  every  few  hours,  so  as 
to  keep  them  moist.  Constant  irrigation  (p.  38)  is  often  of  great 
value  (Fig.  122).  If  no  undue  rise  of  temperature  or  local  pain 
indicates  excessive  reaction,  the  wound  need  not  be  inspected  until 
the  third  or  fourth  day;  and  if  then  the  surgeon  finds  evidence  of 
damming  up  of  secretions,  abscess  formation,  or  beginning  cellu- 
litis, he  should  not  hesitate  to  remove  as  many  sutures  as  requisite 
(all,  if  necessary),  and  institute  treatment  as  for  an  infected  wound 
(see  below).     In  such  cases  the  wound  gradually  becomes  converted 


Fig.  122.  —  Constant  irrigation 
for  crushes,  contused  and  lacerated 
wounds,  etc.  The  solution  drips  over 
the  injured  part  by  gauze  syphonage. 
Episcopal  Hospital. 


INFECTED   WOUNDS  169 

into  an  ulcer,  and  should  be  treated  accordingly.  The  more  free 
from  infection  a  granulating  area  can  be  kept,  the  more  rapidly  the 
surrounding  skin  will  proliferate  and  cover  the  granulations.  If  the 
skin  is  prevented  by  sepsis  from  thus  proliferating,  the  wound  depends 
for  closure  upon  a  infract  inn  of  its  base;  this  results  in  a  thickened 
and  unsightly  scar. 

Infected  Wounds;  Chemical  Sterilization  and  Secondary  Suture. — The 
first  requisite  in  the  treatment  of  an  infected  wound,  which  resembles 
a  phlegmon  (p.  46)  rather  than  an  abscess,  is  that  it  be  provided  with 
free  drainage  for  the  products  of  inflammation.  In  the  vast  majority 
of  cases,  when  this  has  been  accomplished,  the  unaided  forces  of 
nature  will  procure  healing,  so  long  as  no  additional  infection  is 
admitted.1  But  there  are  wounds  which  will  not  heal  of  themselves, 
or  whose  healing  unaided  by  chemical  disinfection  will  take  an  inordin- 
ate time;  hence  all  through  the  history  of  surgery  efforts  have  been 
made  to  aid  nature  by  various  applications  to  the  surface  of  the 
wound.  But  the  difficulty  has  been  that  the  intermittent  application 
of  antiseptics  in  concentrated  form,  even  if  it  succeeded  in  destroying 
numerous  bacteria,  also  destroyed  the  tissues  to  which  they  were 
applied.  The  ideal  procedure  is  to  employ  a  solution  of  a  certain 
strength  (or  rather  of  a  certain  weakness)  which  shall  by  continuous 
application  kill  the  bacteria  without  injuring  the  underlying  tissues. 

Preparation  of  the  wound  for  chemical  sterilization  is  indispensable: 
so  long  as  all  parts  of  the  wound  are  not  readily  accessible  to  the 
action  of  the  chemical  disinfectant,  and  so  long  as  drainage  is  imper- 
fect,2 sterilization  cannot  be  obtained.  Without  providing  complete 
accessibility,  and  without  adequate  drainage,  it  may  be  possible  to 
keep  the  patients  from  becoming  septic  and  to  permit  nature  to  procure 
gradual  healing  of  the  wound  even  without  its  sterilization;  but  in 
such  circumstances  the  main  object  of  the  process,  secondary  suture 
of  the  wound,  will  not  be  a  safe  procedure.  In  most  wounds  infected 
with  the  hemolytic  streptococcus  this  is  the  best  that  can  be  hoped 
for:  by  the  time  the  wound  is  sterilized  by  chemical  disinfectants 
it  will  be  found  to  have  healed  of  its  own  accord.  But  with  wounds 
infected  by  other  relatively  innocuous  bacteria  chemical  disinfection 
often  may  be  procured  within  ten  days  or  two  weeks,  and  when  this 
sterility  has  been  maintained  for  a  period  of  from  four  to  six  days,  then 
secondary  suture  (p.  203)  proves  very  successful. 

Proper  preparation  of  an  infected  wound,  therefore,  often  requires  a 
secondary  operation,  in  the  nature  of  debridement,  sequestrotomy,  etc. 

1  The  value  of  heliotherapy  in  tuberculous  conditions  (p.  527),  and  of  exposures 
to  ordinary  electric  light  in  bed-sores  (p.  61),  is  well  recognized;  and  similar 
measures  often  are  useful  in  the  conditions  now  under  discussion. 

2  The  theory  formerly  held,  that  dependent  drainage  is  harmful  and  interferes 
with  the  Carrel  technique,  has  been,  1  believe,  abandoned  by  all  intelligent  sur- 
geons; for,  as  soon  as  Dakin's  solution  forms  puddles,  it  ceases  to  be  actively 
antiseptic. 


170 


tNJURIES  AND  THEIR  EFFECTS 


Carrel-Dakin  Method  of  Dressing  Septic  Wounds. — Dakin,  an  English 
chemist,  came  to  the  conclusion  from  experimental  work,  that  a  solu- 
tion of  sodium  hypochlorite,  varying  in  strength  only  between  0.45 
and  0.5  per  cent.,  and  free  from  caustic  alkali,  fulfilled  the  require- 
ments of  an  ideal  antiseptic.1  As  the  strength  of  the  solution  rapidly 
diminishes  when  introduced  into  the  wound,  it  is  necessary  to  provide 
for  its  periodic  renewal  as  well  as  for  bringing  it  into  constant  contact 
with  all  parts  of  the  wound,  as  it  is  nearly  impossible  to  sterilize  one 


Fig.  123. — Carrel-Dakin  treatment  for  chronic  osteomyelitis  of  femur,  following  gunshot 
wound.      Walter  Reed  General  Hospital. 

part  of  a  wound  while  others  remain  septic.  For  these  purposes  Carrel, 
a  French  laboratory  worker,  in  association  with  Dakin  (1916),  sys- 
tematized a  method  of  wound  dressing  which  goes  by  his  name;  it  is 
an  assemblage  of  many  equally  important  items,  and  requires  special 
training  to  employ  it  successfully.  The  wound  having  been  properly 
prepared,  Carrel  tubes  are  introduced  in  such  a  manner  that  when 
the  solution  is  periodically  injected  through  them  it  will  be  brought 
into  contact  with  all  parts  of  the  wround.  These  tubes,  of  the  size 
of  No.  18  Fr.  catheters  (p.  1014),  are  tied  at  one  extremity  and  are 
perforated  from  this  point  upward  with  numerous  (8  to  every  5  cm.) 
fine  holes  (0.5  mm.  in  diameter),  made  with  a  2  mm.  punch,  the  tubes 
being  stretched  before  the  perforations  are  made.     These  perfora- 

1  The  hypochlorites,  in  various  forms,  had  been  employed  in  surgery  many 
years  ago,  notably  as  Labarraqne's  solution  of  chlorinated  soda  (2.6  per  cent.)  and 
as  the  eau  de  Javelle.  Eusol  ("Edinburgh  University  Solution"),  introduced  in 
1915  by  Lorraine  Smith,  is  made  thus:  to  one  liter  of  water  add  12.5  gm.  of  com- 
mercial chlorinated  lime;  shake  vigorously;  then  add  12.5  gm.  boric  acid  powder 
and  shake  again.     Let  the  mixture  stand  overnight,  and  filter  before  using. 


INFECTED  WOUNDS  171 

tions  should  all  lie  within  the  wound  when  the  tubes  are  placed.  In 
most  wounds  it  is  best  to  lay  a  single  thickness  of  gauze  over  the 
granulations  and  to  place  the  irrigating  tubes  gently  on  this,  since  in 
this  way  the  solution  is  more  evenly  distributed  to  the  wound  surfaces. 
Very  little  other  dressings  are  applied  except  very  large  cotton  pads 
encased  in  gauze,  which  are  loosely  attached  to  the  part  by  being 
clipped  together.  A  number  of  tubes  may  be  connected  by  glass 
elbows  to  one  main  afferent  tube  which  leads  from  the  receptacle  hung 
at  the  bedside  (Fig.  123).  Every  two  hours  or  oftener  the  nurse  lets 
run  into  the  irrigating  tube  a  quantity  of  solution  sufficient  to  moisten 
(not  to  flush)  thoroughly  all  the  wound  surfaces.  When  properly  used 
there  is  no  gross  overflow  from  the  dressings,  and  the  patient  is  not 
constantly  wet  and  miserable.1  Once  daily  a  strictly  aseptic  dressing 
is  done,  the  tubes  withdrawn,  new  tubes  replaced,  after  caring  for  the 
neighboring  skin  with  neutral  soap,  and  alcohol,  and  then  drying  it 
thoroughly.  The  surrounding  skin  must  in  all  cases  be  protected 
from  possible  contact  with  the  solution  which  might  trickle  out  of  the 
wound,  by  being  covered  with  strips  of  bandage  gauze  impregnated 
with  vaselin,  or  by  being  anointed  with  zinc  oxide  ointment. 

At  each  alternate  dressing,  according  to  the  strict  Carrel  technique, 

1  Dakin's  Solution.  This  is  an  aqueous  solution  of  sodium  hypochlorite  never 
weaker  than  0.45  or  stronger  than  0.5  per  cent.  It  must  be  free  from  irritating 
contamination  such  as  free  alkali  or  free  chlorin.  Daufresne's  method  of  prepara- 
tion is  satisfactory  where  only  small  quantities  are  being  used.  If  larger  quanti- 
ties are  employed  it  is  better  to  prepare  it  from  chlorin  gas  passed  into  a  solution 
of  sodium  carbonate.  It  is  a  very  unstable  solution,  should  be  prepared  fresh 
daily,  should  never  be  heated,  nor  exposed  to  the  light.  Commercial  preparations 
are  valueless. 

1.  To  make  10  liters  take: 

Chlorinated  lime    (bleaching  powder,   having  25   per  cent. 

active  chlorin) 200  grams 

Sodium  carbonate  (dry)  Solvay         100      " 

Sodium  bicarbonate 80      " 

(The  average  strength  in  chlorin  of  the  bleaching  powder  must  be  determined, 
as  the  quantity  of  the  various  ingredients  varies  according  to  this  factor.) 

2.  Place  in  a  12-liter  flask  the  200  grams  of  chlorinated  lime  and  5  liters  of  water. 
Shake  thoroughly  two  or  three  times  and  leave  in  contact  over  night. 

3.  Dissolve  in  5  liters  of  cold  water  the  carbonate  and  bicarbonate  of  soda. 

4.  Pour  the  solution  of  the  sodium  salts  into  the  flask  containing  the  macerated 
chloride  of  lime,  shake  thoroughly  for  one  minute  and  then  let  the  calcium  car- 
bonate settle. 

5.  After  half  an  hour  syphon  off  the  supernatant  liquid  and  pass  it  through 
a  double  filter  paper.  This  perfectly  clear  product  should  be  preserved  cool  and 
protected  from  light  (in  a  dark  colored  bottle). 

After  manufacture,"  Dakin's  solution  must  next  be  tested  for  its  alkalinity: 
Pour  20  c.c.  into  a  glass  and  add  a  few  centigrams  of  powdered  phenolphthalein. 
Agitate  the  liquid  as  if  rinsing  a  glass.  A  red  tint  indicates  the  presence  of  a 
quantity  of  free  alkali,  or  an  incomplete  carbonation  due  to  faults  in  the  technique. 

The  completed  solution  must  also  be  titrated:  To  10  c.c.  of  solution  add  20 
c.c.  of  1  to  10  iodide  of  potassium  solution  and  20  c.c.  of  acetic  acid.  To  this 
mixture  add  a  decinormal  solution  of  sodium  hyposulphite,  until  discoloration. 
Let  n  equal  the  number  of  cubic  centimeters  of  hyposulphite  employed;  then  the 
amount  of  hypochlorite  present  in  100  c.c.  of  the  Dakin's  solution  will  equal 
n  X  0.0375.  (Carrel  and  Dehelly:  Le  Traitement  des  Plaies  Infectees,  2e  ed., 
Paris,  1917.) 


172  INJURIES  AND  THEIR  EFFECTS 

a  smear  is  taken  from  the  mos1  infected  parts  of  the  wound  by  means 
of  a  standard  loop,  and  the  number  of  bacteria  per  microscopic  field 
i>  counted  and  charted;  over  00  to  a  field  is  counted  as  infinity,  but 
when  for  three  or  four  successive  days  there  have  been  no  bacteria 
it  is  considered  safe  to  do  secondary  suture.  As  pointed  out  else- 
where (p.  '202)  it  is  probable  that  the  quality  rather  than  the  quantity 
of  the  infecting  organisms  (within  reasonable  limits)  is  the  important 
factor  in  permitting  secondary  suture.  If  the  bacterial  curve  shows 
a  plateau  it  is  an  indication  of  some  focus  of  infection  which  requires 
operative  removal. 

Fiessinger  and  Clogne  (1918)  have  demonstrated  that  hypochlorites 
are  detergent  rather  than  bactericidal,  and  it  has  been  pointed  out  by 
Hart  well  and  Butler  (11)18)  that  the  more  tissue  debris  there  exists 
in  a  wound  the  more  efficient  is  Dakin's  solution;  in  contact  with 
normal  tissues  it  calls  out  such  a  quantity  of  body  fluids  that  in  less 
than  one  minute  it  falls  below  standard  strength.  Hence  its  use 
should  not  be  continued  when  the  sloughs  are  all  digested  and  dissolved, 
but  some  other  antiseptic  should  be  adopted  if  the  wound  is  still  not 
sterile.  A  caution  should  be  uttered  also  on  the  danger  of  secondary 
hemorrhage  should  Dakin's  solution  digest  a  ligature  on  an  important 
vessel;  silk  and  linen  are  more  liable  to  destruction  than  catgut. 

Dichloramin-T '. — This  is  another  of  Dakin's  preparations,  used  in 
5  to  20  per  cent,  solution  in  chlorcosane.  It  is  more  stable  than 
the  hypochlorite  solution,  is  not  so  irritating  to  the  skin,  retains 
its  potency  when  in  contact  with  the  wound  for  eighteen  to  twenty- 
four  hours,  and  its  use  does  not  require  the  complicated  technique  of 
Carrel.  The  solution,  when  kept  in  dark  colored  bottles,  may  be 
preserved  for  two  or  three  weeks.  At  no  time  should  it  be  in  contact 
with  water,  alcohol,  or  hydrogen  peroxide  (Lee  and  Furness,  1918); 
benzine  is  preferred  for  cleaning  the  skin.  At  the  time  of  operation  on 
infected  parts  a  20  per  cent,  solution  is  applied  to  the  surfaces,  and 
the  wound  is  lightly  packed  with  gauze  soaked  in  the  solution.  Evapo- 
ration should  be  encouraged,  and  not  more  than  four  layers  of  gauze 
are  applied  to  the  wound  surface,  and  are  lightly  held  in  place  by  a 
few  turns  of  a  gauze  bandage.  Dressings  are  not  required  oftener 
than  once  in  twenty-four  hours,  and  at  these  a  weaker  solution  (5  per 
cent.)  usually  suffices;  this  is  sprayed  over  the  entire  wound  or  if  all 
parts  are  not  accessible  to  the  spray,  gauze  wicks  soaked  in  the  oil 
are  introduced  so  as  to  bring  the  solution  into  contact  with  all  parts  of 
the  wound  area. 

Mencieres  Technique. — The  solutions  advocated  by  Menciere  (1916) 
are  used  much  in  the  same  manner  as  is  dichloramin-T.  The  embalm- 
ing solution1  is  applied  at  the  time  of  the  original  debridement,  as 

1  Iodoform, 
Guaiacol, 
Eucalyptol, 

Balsam  of  Peru aa       10  grams 

Alcohol  (denatured) 100       " 

Ether q.s.  ad         1  liter 


PUNCTURED  WOUNDS 


173 


iodin,  dichloramin-T,  or  any  other  efficient  antiseptic;  the  water1  is 
used  in  large  quantities  (several  liters)  to  flush  the  wound  at  the  daily 
dressing;  while  the  pommade2  is  used  when  granulations  are  well 
advanced.  In  wounds  originally  septic,  he  advocates  thorough 
phenolization  followed  by  embalment  with  the  solution. 

It  may  be  remarked  once  more  that  any  and  all  methods  of  chemical 
disinfection  are  secondary  to  thorough  debridement  and  drainage  of 
infected  wounds. 


Figs.  124  and  125. — Skiagraphs  to  localize  needle  in  palm  of  hand. 

Punctured  Wounds. — Punctured  wounds,  as  the  term  indicates, 
are  those  produced  by  pointed  instruments,  and  their  importance 
arises  from  the  fact  that  infection  (not  rarely  tetanus)  is  frequent, 
as  no  free  drainage  exists;  and  because  injury  to  deep  structures 
(viscera,  joints,  nerves,  etc.),  may  pass  unperceived  at  first.  In 
ordinary  practice  punctured  wounds  are  produced  most  often  by 
needles,  nails,  hat  pins,  splinters,  umbrella  tips,  etc.  If  a  needle 
remains  in  place,  with  part  of  the  shaft  projecting  from  the  wound, 
it  should  be  extracted,  and  unless  known  to  be  seriously  infected, 
it  is  sufficient  to  cleanse  the  surrounding  skin  and  apply  an  aseptic 
dressing.  In  a  patient  at  the  Episcopal  Hospital  a  hat  pin  which 
punctured  the  chest  produced  no  symptoms  of  any  kind,  though 

1  Benzoic  acid 200  grams 

Guaiacol 1000      " 

Alcohol 800      " 

Add  of  this  "mother  liquid"  10  c.c.  to  a  liter  of  water  to  make  the  "water"  of 
Menciere. 

2  This  is  the  same  as  the  solution,  except  that  vaselin  (1  kilogram)  replaces  the 
alcohol  and  ether. 


174  INJURIES  AND   Til  KIR  EFFECTS 

from  the  depth  and  direction  of  the  wound  it  is  certain  that  the 
liver,  diaphragm,  and  lung  were  all  traversed.  If  the  point  has  broken 
off  and  is  completely  buried  in  the  tissues,  an  immediate  attempt  to 
extract  it  should  be  made  if  its  position  can  be  detected  by  palpation; 
if  no  clue  as  to  its  location  exists  attempt  at  extraction  should  not 
be  made  until  it  lias  been  accurately  located  by  the  use  of  the  a'-rays, 
two  exposures  in  planes  at  right  angles  to  each  other  being  made 
(Figs.  124  and  125).  The  incision,  for  which  local  anesthesia  some- 
times is  sufficient,  should  be  made  obliquely  to  the  course  of  the 
needle,  being  thus  more  apt  to  strike  it  than  if  made  parallel.  A 
needle  buried  in  the  palm  is  best  exposed  by  turning  up  a  flap  of 
skin.  If  a  large  joint  has  been  punctured,  the  part  should  be  immo- 
bilized, the  patient  being  kept  in  bed  if  necessary.  In  wounds  from 
splinters  and  rusty  nails  the  danger  of  tetanus  developing  is  greater; 
accordingly  the  puncture  should  be  slit  up,  to  ensure  the  removal  of 
all  parts  of  the  splinter,  and  to  allow  the  application  of  antiseptics 
to  all  parts  of  the  wound;  and  an  immunizing  dose  of  antitetanic 
serum  should  be  given. 

Stab  wounds  occasionally  are  seen  in  civil  practice;  they  partake 
of  the  nature  of  both  incised  and  punctured  wounds,  and  like  the 
latter  are  of  interest  chiefly  from  the  implication  of  joints,  internal 
organs,  bloodvessels,  nerves,  etc.  Their  treatment  is  considered 
in  the  chapter  dealing  with  the  surgery  of  these  structures.  Bayonet 
wounds  are  seldom  seen  nowadays,  even  in  military  surgery.  In 
battles  with  Indians  and  other  uncivilized  tribes  arrow  wounds  are 
sometimes  encountered.  The  arrow-head  is  venr  easily  detached 
from  the  shaft,  and  reckless  attempts  to  extract  the  weapon  frequently 
result  in  the  head  breaking  off  and  remaining  in  the  tissues  as  a  foreign 
body.  Sometimes  it  is  better  to  push  the  arrow  on  and  extract  it 
through  the  counterpuncture.  Indian  arrows  were  frequently 
poisoned  with  rattlesnake  venom  or  with  earth  containing  tetanus 
germs,  and  Schell  found  it  a  universal  custom  to  dip  the  points  in 
blood  which  was  allowed  to  dry  on  them;  but  such  practices  are 
rare  at  the  present  day. 

Tooth  wounds,  especially  those  due  to  human  bites,  are  apt  to  be 
severely  infected.  Dog  bites  are  less  dangerous  than  those  of  cats, 
rats,  and  other  domestic  animals.  Monkey  and  parrot  bites  are  not 
very  rare.     I  have  treated  a  case  of  mole  bite. 

Poisoned  Wounds. — Under  this  heading  it  is  convenient  to  consider 
snake  bites  and  insect-stings.  The  latter  are  seldom  serious  in  this 
part  of  the  country,  but  in  the  tropics  are  sometimes  fatal.  The 
lesion  consists  in  a  localized,  occasionally  a  spreading  cellulitis, 
which  is  treated  by  evaporating  and  antiseptic  lotions.  The  pain 
of  stings  is  quickly  allayed  by  plastering  the  bite  with  liquid  mud, 
which  should  be  washed  off  so  soon  as  antiseptics  are  available; 
aqua  ammonise  also  relieves  the  pain  and  neutralizes  the  acid  poison. 

S7iake  Bites. — Snakes  (ophidia)  are  divided  into  two  main  classes, 
the  Colubrines,  mostly  harmless,  and  the  Viperines,  usually  poisonous 


POISONED   WOUNDS  175 

[thanatophidia — death-snakes).  To  know  whether  the  injury  is  from 
a  harmless  or  a  poisonous  snake,  the  bite  should  be  examined:  "If 
the  snake  is  harmless,  two  uniform  rows  of  tooth  marks  will  be  found ; 
if  there  are  two  or  more  distinct  fang-marks,  with  or  without  tooth- 
marks,  the  snake  is  poisonous"  (Fig.  126)  (Mason,  1907).  The 
venom  is  contained  in  a  sac  at  the  base  of  the  hollow  fang,  which  is 
on  the  upper  jaw;  this  sac  is  compressed  by  the  muscles  which  close 
the  jaws,  and  the  virus  is  squirted  through  the  hollow  fang  much 
as  through  a  hypodermic  needle.  Repeated  biting  soon  empties 
the  poison  sac,  and  the  snake  is  then  comparatively  harmless  until 
more  virus  has  been  secreted. 

The  most  important  constituents  of  snake  venom  are  a  globulin 
and  a  peptone.  The  former  destroys  the  coagulability  of  the  blood, 
and  produces  molecular  changes  in  the  vessel  walls;  this  accounts 
for  the  extravasation  and  hemorrhages  (subcutaneous,  gastro- 
intestinal, renal),  which  are  characteristic  of  snake  poisoning.  The 
peptone  produces  locally  "  rapid 
edema,        putrefaction,        and 

sloughing    without     extravasa-       /  •     \  \  •   :  '•  * 

tion;     constitutionally,     it    in-      :   :'       •    -:  •  :"     • 

creases   blood-pressure,  acceler-      •    :        :    •  :.      • 

at'es  the  respiration,  and  often      :    •       •    :  •      • 

causes    convulsions."     (Mason,      •    \     •     ;  \    : 

1907.)      In    rattlesnake     bites,       •     •     :     : 
almost  the   only   kind  seen   in  •  •    : 

this   country,    death  occurs    in 

from  12  to  25  per  Cent,  of  Cases,  FlG.  126._ Tooth  marks    made    by    snake 

USUally     within    twenty-four    to  bites:  on  the    left  a    harmless    snake;    fang- 

.  .        "   .        .                    t\        i      e  marks  in   the  center  and  on    the  right    lndi- 

thirty-SLX     hours.       Death     from  Cate  a  poisonous  snake. 

cobra  bites,  which  are  frequent 

in  India,  and  not  very  rare  in  the  Philippines,  occurs  usually  in  a  few 
hours.  Bites  of  copper-heads  and  moccasins  are  not  so  dangerous, 
though  amputation  may  be  required  for  sloughing,  or  septicemia 
may  kill  at  a  later  date. 

Treatment  consists,  locally,  in  the  immediate  application  of  a 
ligature  or  tourniquet  around  the  limb  above  the  wound,  and  in 
suction  of  the  punctures  by  the  mouth,  or  by  cupping  glasses  when 
available.  The  venom  is  not  poisonous  when  taken  by  mouth,  if 
the  stomach  is  full;  but  it  should  of  course  be  spat  out.  Free  incisions 
will  make  suction  more  effective.  Amputation  or  excision  of  an 
unimportant  part  may  be  done.  The  ligature  should  be  used  inter- 
mittently, admitting  only  small  doses  of  the  venom  into  the  circula- 
tion at  one  time;  and  when  the  wound  is  far  enough  from  the  trunk 
to  make  it  possible,  it  is  well  to  apply  a  high  and  a  low  ligature 
alternately.  Mason  also  recommends  that  the  limb  be  bandaged 
from  its  two  extremities  toward  the  wound,  so  as  to  squeeze  out  all 
the  venon  possible.  The  best  local  applications  after  free  incision 
are  oxidizing  agents,  such  as  peroxide  of  hydrogen,  or  1  per  cent. 


176 


INJURIES  AND   THEIR  EFFECTS 


solutions  of  potassium  permanganate  or  chromic  acid.  The  actual 
cautery  (hot  coals,  burning  gun-powder)  should  be  employed  if  these 
remedies  are  not  at  hand.  Local  treatment  should  be  prompt,  as  it 
is  probably  useless  after  the  lapse  of  half  an  hour.  In  cobra  bites  Cal- 
mette's  serum  (antivenene)  should  always  be  employed  when  available; 
hypodermic  injections  of  10  to  20  c.c.  of  the  stronger  serum  are 
given  as  soon  as  possible.  Gastric  lavage  and  catharsis  are  indicated 
to  remove  the  venom  excreted  into  the  gastro-intestinal  tract.  Hope 
should  not  be  abandoned  too  soon,  some  remarkable  recoveries  being 
recorded  after  the  prolonged  use  of  artificial  respiration. 

Burns  and  Scalds. — The  effect  is  essentially  the  same  whether 
the  injury  is  produced  by  flame  (bum)  or  by  hot  liquid  (scald).  In 
scalds,  however,  the  hair  usually  remains  intact,  while  in  burns  it 
is  singed.     Gas  and  acid  burns-  are  mentioned  at  p.  178. 

Symptoms. — Local  symptoms  vary  with  the  degree  of  heat  and  the 
length  of  contact:  mere  singeing  of  the  hair  and  a  passing  erythema 
may  be  caused  by  momentary  contact  of  flame,  while  prolonged 
contact  with  some  body  at  much  lower  temperature  (e.  g.,  hot  water 
bottle)  may  produce  a  very  destructive  lesion.  Burns  may  be  classi- 
fied in  three  degrees:  (1)  Erythema.  (2)  Vesicles  and  Bullae.  (3) 
Sloughing.  The  reactionary  changes  which  occur  in  the  burned  part 
are  identical  with  those  already  discussed  in  the  chapter  on  Inflam- 
mation. 


Fig.  127. — Scald  of  hand,  second  degree;  twelve  hours'  duration;  showing  bullae. 
Episcopal  Hospital. 

Constitutional  effects  of  burns  depend  much  more  on  the  area 
involved  than  on  the  depth  of  the  burn.  A  superficial  burn  may  be 
attended  by  the  gravest  consequences,  even  death,  if  extensive; 
whereas  a  very  deep  burn,  if  it  involves  only  a  small  area,  may  be 
almost  unattended  by  constitutional  symptoms.  As  in  other  injuries, 
the  constitutional  effects  of  burns  may  be  divided  into  those  of  shock 
and  reaction;  and  there  usually  follows,  in  severe  cases,  a  stage  of 
exhaustion.  The  pain  is  intense,  and  in  extensive  burns  may  induce 
hyperpnea,  which,  according  to  the  theory  of  Henderson  (p.  181), 
produces  acapnia,  and  so  induces  shock;  patients  may  die  in  the  first 
stage,  without  reaction.  The  unburned  skin  is  pale,  the  patients 
feel  chilly,  and  require  to  be  covered  up;  the  usual  signs  of  shock 
are  present.  Often,  however,  reaction  begins  soon,  sometimes  before 
the  patient   is  seen  by  the  surgeon;    and    at    this    time   prostration 


BURNS  AND  SCALDS  177 

with  excitement  or  traumatic  delirium  (p.  183)  may  dominate  the  scene. 
This  stage  lasts  for  a  week  or  more,  being  accompanied  by  high 
fever,  often  with  intense  congestion  of  organs  underlying  the  lesion 
(pneumonia,  in  thoracic  burns;  peritonitis,  in  those  of  the  abdomen; 
meningitis  in  those  of  the  head) .  There  is  a  tendency  to  fatty  degener- 
ation of  all  organs;  the  liver,  spleen,  and  lymph  nodes  may  be  enlarged; 
the  urine  is  scanty,  of  high  specific  gravity,  or  entirely  suppressed. 
The  bile  is  believed  to  be  abnormally  toxic.  The  blood  is  prone  to 
thrombosis,  and  capillary  embolism  is  not  infrequent;  there  is  hyper- 
leukocytosis  and  polycythemia;  hemoglobinuria  and  albuminuria 
may  exist.  The  patient  is  excessively  thirsty,  but  constantly  vomits 
what  is  taken  into  the  stomach;  there  may  be  septic  diarrhea;  he 
feels  hot,  is  restless,  and  tosses  off  the  bed-clothes.  If  he  survives  this 
stage,  there  follows  that  of  exhaustion,  with  hectic  fever,  profuse  sup- 
puration of  the  wounded  surfaces,  and  perhaps  metastatic  (especially 
subcutaneous)  abscesses. 

Death  from  Burns  may  be  due  to  shock,  to  visceral  complications, 
to  exhaustion,  or  to  hemolysis  and  auto-intoxication.  Among  the 
visceral  complications  may  be  included  edema  of  the  glottis,  from 
inhalation  of  steam  or  hot  smoke.1  In  fatal  cases,  death  usually 
occurs  within  forty-eight  hours. 

Prognosis. — In  local  burns  prognosis  as  to  life  is  good,  even  if  the 
part  be  much  deformed  by  subsequent  cicatricial  contraction.  Burns 
of  the  trunk  are  more  serious  than  those  of  the  extremities.  If  a  burn 
involves  more  than  one-third  of  the  body  surface  it  usually  is  fatal. 
General  burns  are  always  fatal.  Burns  are  particularly  serious  in 
infants,  the  aged,  those  of  intemperate  habits,  those  with  diseased 
kidneys,  etc. 

Treatment. — The  indications  in  all  cases  are  to  control  the  pain, 
to  combat  the  shock,  and  to  prevent  injection.  In  severe  cases,  where 
death  is  anticipated,  the  most  that  can  be  done  is  to  promote  euthan- 
asia. Shock  is  combated  as  described  at  p.  184;  especially  important 
is  the  dilution  of  the  blood  by  saline  solution,  which  relieves  toxemia 
and  at  a  later  stage  restores  the  fluid  contents  depleted  by  discharges 
from  the  burned  surfaces.  Massive  burns  with  charred  skin  should  be 
treated  by  immediate  excision  of  the  roasted  area  in  the  effort  to 
prevent  toxemia.  Prevention  of  infection  involves  local  treatment  of 
the  lesions;  anything  which  protects  them  from  the  air  lessens  pain, 
and  in  extensive  burns  the  simplest  and  best  treatment  is  to  spray  the 
surface  every  two  or  three  hours  with  some  warm  oily  substance,  such 
as  liquid  albolene;  no  dressing  is  applied,  but  the  patient's  entire 
body  is  kept  warm  and  dry  by  exposure  to  electric  light  bulbs  hanging 
from  a  cradle,  itself  covered  by  bedclothing.  When  granulations 
develop,  burns  of  large  extent  should  be  immersed  in  a  continuous  bath 

1  In  rare  cases  duodenal  ulceration  (Curling,  1842),  with  hemorrhage  or  perfor- 
ation, develops,  possibly  from  excretion  of  toxic  substances  through  Brunner's 
glands,  or  as  the  result  of  embolism.  Alexander  (1912)  observed  this  complica- 
tion in  four  out  of  twenty-seven  patients  with  extensive  burns. 

12 


17S  INJURIES  AND  THEIR  EFFECTS 

(saline  or  boric  acid)  for  three  hours  at  a  time,  with  intermissions  of 
six  hours,  until  sloughs  are  removed.  In  hums  of  less  extent  it  makes 
little  difference  what  dressing  is  applied,  so  long  as  it  is  aseptic,  and 
absorbs  or  does  not  dam  up  the  discharges.  Spray  the  burned  surface 
lightly  with  peroxide  of  hydrogen,  and  surgically  cleanse  the  sur- 
rounding parts.  Do  not  scrub  the  burns.  Open  bullae  with  a  sterile 
knife,  and  let  the  epidermis  fall  back  in  place  as  the  serum  escapes. 
The  following  may  be  used  in  recent  burns  of  the  first  and  second 
degree:  Picric  acid  dressing:  gauze  soaked  in  1  per  cent,  aqueous 
solution  is  laid  on  the  burn  and  covered  with  absorbent  cotton,  not 
with  waxed  paper,  as  evaporation  should  be  favored;  the  dressing  is 
left  in  place  four  or  five  days.  It  should  be  used  only  over  small 
areas,  as  constitutional  poisoning  has  occurred.  Senn's  powder  (boric 
acid,  three  parts;  salicylic  acid,  one  part)  or  Billroth' 's  powder  (equal 
parts  of  starch  and  zinc  oxide)  may  be  applied  to  small  burns,  and 
form  a  scab  which  need  not  be  removed  for  several  days.  So  soon 
as  granulations  have  formed,  the  burn  is  treated  as  an  ordinary  ulcer 
(p.  53).  The  application  of  strips  of  adhesive  plaster  over  the  granu- 
lations keeps  them  from  becoming  exuberant  and  encourages  prolifera- 
tion of  epithelium.  Various  dressings  of  paraffin  impregnated  gauze 
have  been  used  for  the  same  purpose;  or  dichloramin-T  may  be  used. 

When  much  skin  has  been  destroyed,  healing  will  be  slow,  and 
skin-grafting  should  be  employed  (p.  236).  Great  care  must  be 
exercised  by  proper  use  of  splints,  etc.,  especially  in  burns  about 
flexures  of  joints,  to  prevent  undue  cicatricial  contraction;  but  in 
some  cases  healing  can  be  secured  only  as  the  result  of  such  a  process 
(Figs.  197  and  198),  and  the  deformity  must  be  overcome  by  sub- 
sequent plastic  operations  (Figs.  199  and  200).  In  severe  grades  of 
deformity,  with  painful  scars  which  prevent  conservative  operations, 
amputation  may  be  necessary.  Occasionally  epithelioma  develops  in 
such  scars. 

Mustard  Gas  Burns. — Mustard  gas  burns  were  much  seen  in  the 
German  war,  the  gas  especially  attacking  moist  areas  (axilla,  groin). 
So  soon  as  possible  a  soap  and  water  bath  should  be  taken  to  remove 
the  deposit;  and  resulting  burns,  which  may  be  slow  in  development, 
should  be  treated  as  burns  from  other  causes. 

Acid  Burns. — Acid  burns  resemble  those  caused  by  heat,  but  the 
acid  should  at  once  be  neutralized  by  an  alkali;  soap  is  usually  at 
hand. 

Effects  of  Cold. — In  many  ways  these  are  analogous  to  those 
produced  by  heat,  and  depend  more  on  the  length  of  the  exposure 
than  on  the  intensity  of  the  cold;  moist  cold,  especially  in  a  high 
wind,  is  much  more  apt  to  produce  serious  effects  than  a  still,  dry 
cold. 

Constitutional  Effects. — Among  predisposing  causes  are  hunger, 
fatigue,  alcoholism,  etc.  There  occur  painful  sensations  in  the  extremi- 
ties, perhaps  chills,  followed  by  uncontrollable  lassitude,  somnolence, 
coma,  and  death  if  the  patient  is  not  roused.    The  causes  of  death 


FROST-BITE  179 

are  cerebral  anemia  (sudden  and  progressive  chilling);  cerebral  con- 
gestion (slow  and  continuous  chilling) ;  or  embolism,  in  cases  of  sudden 
reheating  (Lebastard).  Persons  apparently  dead  should  be  kept  in 
a  cool  room,  and  treated  by  artificial  respiration  and  gentle  frictions 
with  evaporating  or  stimulating  liniments;  when  reaction  commences 
(perhaps  not  for  several  hours),  the  temperature  of  the  room  may 
be  raised  gradually,  stimulants  administered,  and  the  patient  wrapped 
in  blankets.  Recovery  has  followed  after  being  buried  in  the  snow 
for  eight  days  (Tedenat),  and  when  the  rectal  temperature  had  fallen 
as  low  as  74.6°  F.  (Nieolaysen). 


Fig.  128. — Frost-bite  of  second  degree;  duration,  four  days.     Episcopal  Hospital. 

Frost-bite. — The  local  effect  of  cold  is  analogous  to  that  of  heat, 
and  may  be  classified  in  three  similar  degrees:  Erythema,  Bullse, 
and  Eschar.  The  exposed  part,  especially  the  fingers  and  toes,  nose, 
cheeks,  ears,  or  the  penis,  becomes  first  the  seat  of  congestion,  attended 
by  some  tingling  and  pain;  soon,  however,  the  part  becomes  blanched, 
numb,  and  stiff,  and  to  all  appearances  dead.  This  stage  is  well 
exemplified  when  local  anesthesia  is  produced  by  the  ethyl  chloride 
spray.  With  proper  treatment,  the  local  destruction  may  go  no 
further;  if  this  is  neglected,  vesicles  and  bullae  form  (Fig.  128),  and  if 
the  cuticle  is  destroyed  and  infection  follows,  painful  ulcers  develop 
which  are  long  in  healing.  Finally,  the  freezing  may  be  so  intense 
that  a  local  slough,  or  gangrene  of  an  entire  limb  may  occur,  the 
larger  arteries  and  veins  being  thrombosed. 

Treatment  of  milder  degrees  of  frost-bite  consists  in  gentle  frictions 
with  snow  or  iced  water  until  sensation  is  restored;  the  part,  which 
now  begins  to  tingle  and  burn,  may  next  be  painted  with  silver 
nitrate  solution  (1  or  2  per  cent.),  which  allays  these  symptoms; 
the  part  is  then  protected  from  injury  and  maintained  at  an  even 
temperature  by  absorbent  cotton.  When  gangrene  threatens,  vertical 
suspension  of  the  limb  should  be  adopted  (v.  Bergmann,  1873)  with 
immobilization  by  splints;    as  the  swelling  subsides  the  circulation 


ISO  INJURIES  AND   THEIR  EFFECTS 

improves.  The  resulting  sloughs  are  treated  as  advised  in  Chapter 
II.  Amputation  should  not  be  done  until  the  line  of  demarcation 
has  been  established. 

Pernio  or  Chilblain  is  a  vaso-motor  disturbance  of  the  skin  following 
previous  frost-bite  of  mild  degree.  It  develops  as  the  result  of  sudden 
variations  in  the  temperature  to  which  the  part  is  exposed.  Chilblains 
occur  in  parts  most  exposed  to  frost-bite,  and  are  especially  common 
in  the  anemic  and  run-down.  A  patient  once  affected  is  prone  to 
have  recurrence  of  chilblains  on  slight  provocation.  The  symptoms 
and  treatment  are  much  the  same  as  for  mild  degrees  of  frost-bite. 
Constitutional  treatment  should  not  be  neglected. 

Trench  Feet. — Under  this  name  is  described  a  condition  resembling 
frost-bite  due  to  long  exposure  to  moist  but  mild  cold  in  battle  trenches, 
with  compression  of  the  feet  swollen  inside  the  shoes  and  leggings. 
Prophylaxis  is  very  important,  but  difficult  to  secure.  The  feet 
should  be  frequently  bathed,  thoroughly  dried,  well  powdered  and 
dry  socks  put  on.  When  the  lesions  are  discovered  no  temporizing 
methods  should  be  employed,  but  the  soldier  evacuated.  Delay  may 
result  in  loss  of  part  or  the  whole  of  the  foot.  The  feet  should  be 
maintained  dry  and  in  an  elevated  position,  and  active  movement 
of  all  the  joints  should  be  practised.  Sloughs  and  resulting  ulcers 
are  treated  as  when  due  to  other  causes. 

Electric  Currents. — These  produce  local  effects  (electric  burns) 
and  general  effects  (electric  shocks).  The  former  are  more  severe 
the  less  the  area  of  contact,  while  severe  shocks  and  milder  burns 
follow  broader  contacts.  The  burns  do  not  differ  from  those  due  to 
other  causes  except  in  their  extreme  slowness  in  healing.  Skin-graft- 
ing usually  is  unsatisfactory,  but  a  plastic  operation  may  succeed. 
The  constitutional  effects  of  electric  currents  are  practically  identical 
with  those  due  to  lightning  strokes. 

Lightning  Strokes. — -Death  may  be  instantaneous.  Stunning  almost 
always  is  produced,  and  burns  frequently  exist  at  the  points  of  entrance 
and  exit  of  the  current;  they  resemble  burns  due  to  electric  currents; 
arborescent  marks,  typical  of  lightning  strokes,  are  attributed  to 
disorganization  of  blood  in  the  vessels.  Persons  apparently  dead 
may  recover  after  many  hours;  the  usual  condition  of  a  patient  just 
after  being  struck  by  lightning  resembles  that  seen  in  concussion  of 
the  brain.  Treatment  consists  in  artificial  respiration,  external  heat, 
and  other  methods  advised  for  shock  (p.  184). 

X-ray  Dermatitis. — This  affection,  carefully  studied  by  Codman 
in  1902,  is  seldom  seen  except  as  the  result  of  repeated  and  prolonged 
exposure  to  the  Rontgen  rays;  before  their  danger  was  understood, 
skiagraphers  took  no  precautions  to  protect  themselves  from  exposure, 
and  a  dermatitis  affecting  the  fingers  was  not  unusual.  The  danger 
to  patients  is  extremely  slight,  especially  since  modern  methods 
permit  very  short  exposures.  The  dermatitis  does  not  develop  for 
several  days  after  exposure,  and  then  is  characterized  by  slight 
erythema,  with  pigmentation  and  exfoliation  of  epiderm;  a  severer 


GENERAL  EFFECT  OF  INJURIES  181 

degree  is  evidenced  by  the  formation  of  vesicles  and  bulla3,  while 
the  third  degree  involves  a  slough  of  the  entire  skin.  Eventually, 
dystrophies  of  the  nails,  keratoses,  and  epitheliomas  may  occur. 

Treatment.  —  No  further  exposure  should  be  allowed,  even  if  the 
patient  thinks  himself  well  protected  by  leaden  shields,  etc.  For 
the  intense  pain  which  exists  during  the  extremely  slow  casting  of 
the  slough,  alkaline  astringents  give  the  best  results.  Ointments  are 
said  to  favor  carcinomatous  changes  (Leonard).  When  these  occur, 
amputation  is  necessary. 

Therapeutic  Uses  of  the  X-ray.  —  These  should  be  applied  by  an 
expert  Rontgenologist  in  consultation  with  a  dermatologist.  Some 
cases  of  lupus,  a  few  of  keloid,  and  occasionally  a  case  of  superficial 
epithelioma  may  be  cured,  at  least  temporarily,  by  periodic  exposure 
to  the  x-rays.  Their  action  appears  to  consist  in  stimulating  an 
over-production  of  fibrous  tissue,  by  which  the  growth  of  the  cellular 
elements  is  arrested  or  abolished.  After  operation  for  carcinoma,  and 
in  inoperable  cases,  systematic  treatment  with  the  x-rays  may  delay 
recurrence,  diminish  pain,  and  greatly  promote  the  patient's  comfort. 

Therapeutic  Uses  of  Radium. — What  was  said  of  the  use  of  the 
.r-rays  applies  also  to  that  of  radium;  when  used  by  the  ignorant, 
in  inefficient  doses,  radium  emanations  do  more  harm  than  good. 
When  properly  used,  their  effect  in  certain  cases  of  sarcoma  and  car- 
cinoma, in  Hodgkin's  disease,  and  allied  conditions,  sometimes  is 
marvellous.  They  may  secure  freedom  from  recurrence  for  a  number 
of  years,  but  rarely  cure  the  disease  definitely.  As  the  same  is  the 
best  that  can  be  said  of  surgical  operations  in  some  cases,  it  is  wrell 
to  consider  treatment  by  radium  when  such  is  available;  but  the 
fact  remains  that  in  the  majority  of  cases  the  results  of  operation 
are  more  certainly  known  in  advance,  and  therefore  usually  to  be 
preferred. 

GENERAL  EFFECTS    OF  INJURIES. 

Shock. — The  primary  constitutional  effect  of  injury  is  named 
shock.  The  term  dates  from  1795  (James  Latta).  Certain  clinical 
states  previously  confused  with  shock  were  first  clearly  distinguished 
from  it  in  1871  by  John  Ashhurst,  Jr.1  Such  especially  were  hemor- 
rhage, concussion  of  the  brain,  syncope,  etc.  Subsequent  experi- 
mental studies,  as  Quenu  points  out,  again  served  to  confuse  these 
various  states,  and  for  the  last  generation  the  utmost  vagueness  has 
existed  in  the  ideas  of  many  surgeons  and  physiologists  as  to  what  is 
and  what  is  not  shock.  Crile  (1899)  attributed  shock  largely  to 
interference  with  the  vasomotor  mechanism,  from  injury  of  peripheral 
nerves  (see  footnote,  p.  149);  but  other  investigators  have  found  it 
difficult  or  impossible  to  produce  symptoms  of  shock  by  injury  to  the 
nerves  alone.  Henderson  (1908)  proposed  the  theory  that  shock 
was  due  chiefly  to  loss  of  the  carbon  dioxide  constituent  of  the  blood, 

1  I  make  this  statement  on  the  authority  of  Prof.  Quenu,  whose  monograph  on 
Traumatic  Toxemia  (1919)  is  the  latest  addition  to  the  literature  of  shock. 


182  TNJV  R I ES  AND   THEl  R  EF  F  E( '  TS 

.1  state  to  which  he  applied  the  term  acapnia;  but,  again,  other  physi- 
ologists claim  that  this  is  the  result,  not  the  cause  of  shock.  Acidosis, 
which  is,  strictly  speaking,  only  a  lessened  alkalinity  of  the  blood, 
always  results  from  hemorrhage,  and  usually  is  present  in  shock. 
Prince  (1918)  considers  it  to  be  compensatory  in  nature,  due  to  the 
acapnia;  but  Cannon  (1918)  recognizes  it  as  the  result  of  destruction 
of  muscle  tissue  at  the  wound  site.  Failure  of  the  circulation  is 
always  present,  but  the  accumulation  of  blood  in  the  splanchnic  area, 
of  which  so  much  was  formerly  said,  is  not  regarded  as  of  constant 
occurrence  in  pure  shock.  The  blood-pressure  falls,  but  the  peri- 
pheral vessels  are  contracted  (witness  the  blanching  of  the  skin,  the 
sweating,  etc.),  and  it  probably  is  in  the  capillaries  that  concentrated 
blood  collects;  its  fluid  constituents  being  largely  expelled  (Archibald, 
1917).  Quenu's  own  theory,  which  has  most  to  support  it,  is  that 
shock  is  a  toxemia  due  to  absorption  of  albuminoid  poisons  developed 
in  the  tissues  which  have  been  mechanically  injured.  Precisely 
similar  symptoms  develop  in  sudden  and  overwhelming  toxemias  due 
to  other  causes  (intraperitoneal  or  intrapleural  rupture  of  an  abscess, 
intestinal  perforation,  cholera,  anaphylaxis,  etc.);  Cannon  and  Bayliss 
(1918)  have  produced  such  symptoms  experimentally  by  crushing 
muscular  tissues,  proving  at  the  same  time  their  independence  of  the 
nervous  system  and  their  dependence  upon  the  circulation;  and 
clinically  the  untimely  removal  of  a  tourniquet  from  a  mangled  limb, 
permitting  sudden  restoration  of  the  circulation,  has  been  known  to 
cause  the  immediate  development  of  profound  shock  (Estes,  1913; 
Quenu,  1919)  » 

It  is  true  that  shock  frequently  accompanies  concussion  of  the 
brain,  syncope  and  hemorrhage;  but  it  may  and  often  does  exist  in 
marked  degree  when  none  of  these  factors  is  present.  It  is  the  prim- 
ary, constitutional  effect  of  injury;  it  is  neither  immediate  nor  second- 
ary, it  is  primary.  It  may  appear  immediately,  or  it  may  be  long 
delayed,  but  usually  a  distinct  though  comparatively  short  interval 
(one-half  to  three  hours)  elapses  betwreen  the  occurrence  of  injury 
and  development  of  the  symptoms  recognizable  as  those  of  shock. 
Usually  the  injury  is  extensive:  crushes  and  mangling  wounds  of  the 
extremities,  especially  muscular  wounds,  or  multiple  wounds  even  if 
each  is  unimportant,  extensive  burns  and  scalds,  and  other  lesions 
without  hemorrhage  and  without  syncope  or  concussion  of  the  brain 
produce  the  typical  symptoms  of  shock. 

Predisposing  Causes. — General  debility,  extreme  youth  and  age, 
and  organic  diseases  (heart,  kidneys,  liver,  etc.)  are  among  the  pre- 
disposing causes.  Exposure  and  chilling,  if  prolonged,  will  increase 
shock.  Hemorrhage,  by  directly  affecting  the  patient's  vitality,  and 
lowering  blood-pressure,  is  probably  the  most  important  predispos- 
ing factor  of  all.  Prolonged  anesthetization  acts  in  a  similar  manner, 
chloroform  causing  lowering  of  blood-pressure  from  the  very  first, 
ether  only  after  long  administration.  Shock  during  or  following 
surgical  operations  is  rare  unless  there  has  been  great  traumatism 

1  I  observed  such  an  occurrence  in  1909. 


SHOCK 


183 


inflicted  by  the  surgeon,  or  unless  there  has  been  hemorrhage  or 
chilling  and  exposure  during  the  operation. 

Symptoms. — The  patient,  if  not  stunned  by  the  injury  or  suffering 
from  cerebral  concussion,  is  conscious,  his  mind  sometimes  being 
clear  and  alert,  but  more  often  semi-stuporous,  as  if  the  effort  even 
to  think  were  exhausting.  The  face  is  pale,  the  lips  ashen  or  slightly 
blue;  the  entire  body  surface  is  pale,  cold,  and  often  clammy;  the 
temperature  is  subnormal  (Fig.  129);  the  eyes  are  staring  or  half- 
closed;  there  may  be  dimness  of  vision  or  actual  blindness  (from 
retinal  anemia);  the  pupils  are  dilated,  and  react  sluggishly  to  light; 
the  respirations  are  shallow  and  rapid;  the  pulse  is  quick,  fluttering, 
weak  and  frequently  uncountable.  Incontinence  of  feces  is  frequent, 
that  of  urine  rare  and  usually  portends  a  fatal  issue.  The  patient 
lies  motionless  wherever  placed.  His  sensibility  is  diminished.  This 
torpid  stage  may  last  a  few  minutes  or  several  days.  Death  may 
occur  without  reaction,  in  spite  of  energetic  treatment.1 

Recovery  may  be  apparently  complete  in  a  few  minutes,  or  may 
occur  gradually,  especially  when  there  is 
some  severe  injury  present.  When  reaction 
occurs,  it  may  be  excessive,  the  patient  be- 
coming mildly  delirious,  and  exhibiting  the 
condition  described  by  Travers  (1827)  as 
prostration  icith  excitement  (erethistic  shock). 
This  condition,  which  occasionally  develops 
immediately  after  the  injury,  the  torpid  stage 
being  extremely  short  or  altogether  absent, 
may  pass  into  true  traumatic  delirium,  an 
affection  probably  due  to  some  form  of 
toxemia.  The  patient  is  restless,  talkative, 
with  bright,  roving  eyes  and  incessant  action ; 
he  is  really  weak,  though  seemingly  strong, 
and  is  liable  to  collapse  at  any  time.  He 
is  pursued  by  frightful  hallucinations,  often  acting  over  and  over 
again  in  his  delirium  the  drama  of  his  injury.  Traumatic  delirium 
should  always  be  regarded  as  a  dangerous  complication,  being  unus- 
ually serious  when  developing  immediately  after  the  accident. 

Collapse  is  not  to  be  confused  with  shock;  it  is  immediate  in  its 
appearance,  and  is  due  to  inhibition  of  the  heart's  action  through 
the  nervous  system.  It  occurs  sometimes  during  operations  on  the 
larynx  and  thoracic  organs. 

Diagnosis. — The  essential  symptoms  of  shock  are  tachycardia,  tachy- 
pnea, hypoesthesia  and  torpidity  of  the  body.  In  hemorrhage  there  is 
restlessness,  not  torpidity;  the  lips  are  blanched  not  livid;  there  is  no 
hypoesthesia  unless  syncope  occurs ;  and  infusion  of  saline  solution  and 
especially  transfusion  of  blood  are  beneficial,  but  rest  without  effect  in 
pure  shock.    Syncope  may  occur  without  history  of  injury,  the  patient 

1  In  shock  alone,  a  blood-pressure  below  80  mm.  of  mercury,  and  in  shock  com- 
bined with  hemorrhage  below  90  mm.  of  mercury,  usually  is  fatal  unless  transfusion 
of  blood  is  done. 


DAY  OF 
MONTH 

5  1  (5  [ 

7  | 

8 

100 
I       » 

<  99 
|  98 

|w 

96 
95 

z 

i 

-y\ 

-  -e— \  ■       - 

A 

Fig.  129. — Shock  and  reac- 
tion. Case  of  multiple  frac- 
tures; man,  aged  thirty  years. 
Episcopal  Hospital. 


IS  I  INJURIES  AND   THEIR  EFFECTS 

becoming  unconscious,  and  possibly  being  subject  to  fainting  fits. 
Psychical  shock  (fright)  should  not  be  mistaken  for  surgical  shock; 
it  may  result  in  death  in  the  absence  of  all  injury,  especially  in  cardiac 
patients,  but  usually  the  mental  trepidation  soon  passes  ofT,  having 
caused  no  more  serious  disturbance  than  a  sinking  feeling  in  the 
prccordiuni,  slight  qualmishness,  and  a  temporarily  accelerated 
pulse.  Erethistic  shock  and  traumatic  delirium  are  to  be  distinguished 
from  deli rin hi  tremens  and  mania  a  potu.  In  these  a  history  of  chronic 
alcoholism  usually  can  be  obtained,  and  the  delirium  is  somewhat 
different  in  character:  in  delirium  tremens  which  may  be  regarded 
as  the  first  stage  of  the  affection,  the  patient  is  fearful  and  shrinking, 
the  delirium  is  muttering,  the  hallucinations  usually  relate  to  insects, 
reptiles,  etc.,  and  the  trembling  of  the  hands  is  characteristic;  in 
mania  a  potu,  the  second  stage,  he  is  violent,  shouting,  cursing  and 
singing,  with  no  fear  of  man  or  devil,  breaking  loose  from  the  bed, 
attempting  to  climb  out  of  the  window,  and  having  no  sensations 
of  the  pains  caused  himself,  grinding  his  broken  bones  together  as 
if  they  were  cobble-stones  (Hunt,  1881),  and  sometimes  wilfully 
mutilating  his  person.  Yet  as  alcoholics  are  prone  to  severe  injury, 
and  therefore  to  shock,  it  is  frequently  impossible  to  say  whether 
the  ensuing  delirium  is  alcoholic  or  purely  traumatic.  The  delirium  of 
uremic  conditions  (Chapter  XXV)  adds  another  confusing  factor  which 
is  often  present  in  injured  alcoholics  and  others  with  diseased  kidneys. 
Prevention  of  Shock. — Maintenance  of  body  heat  and  prevention 
of  further  tissue  destruction  at  the  site  of  injury  by  proper  splinting 
during  transport  (p.  204)  are  the  most  important  measures  for  the 
prevention  of  shock.  A  full  dose  of  morphin  should  be  given  as  soon 
as  possible;  it  checks  cellular  action  and  maintains  a  state  of  rest. 
The  hypodermic  use  of  atropin  is  valuable  in  two  ways:  it  causes  a 
rise  of  blood-pressure  by  central  action,  and  by  paralyzing  the  inhibi- 
tory fibers  of  the  vagus  prevents  injurious  impulses  from  reaching  the 
heart  and  producing  collapse. 

When  an  operation  is  to  be  undertaken  and  shock  is  feared,  nitrous 
oxide  and  oxygen  is  the  best  anesthetic;  ether  is  better  than  chloro- 
form both  because  less  toxic  and  because  for  a  tune  at  least  it  acts  as 
a  cardiac  stimulant.  During  an  operation  the  most  important  means 
of  preventing  shock  are  control  of  bleeding,  gentle  manipulation,  and 
maintenance  of  bodily  heat.  Direct  division  by  the  scalpel  should 
replace  blunt  dissection  and  tearing,  dragging  manipulations  when- 
ever possible.  Mechanical  means  for  maintaining  blood-pressure 
are  discussed  under  Treatment. 

Treatment. — The  indications  are  to  restore  the  circulation,  prevent 
the  loss  of  body  heat,  and  keep  the  patient  alive  (by  artificial  respi- 
ration if  necessary)  until  the  remedies  used  have  time  to  act.  If 
hemorrhage  is  present  it  must  be  checked  (p.  260).  Application  of 
external  heat  is  most  important:  cover  the  patient  warmly,  and  sur- 
round him  with  hot  water  bottles,  hot  bricks,  etc.;  a  current  of  hot  air 
from  an  oil  lamp  may  be  conducted  under  the  bed-clothes.     Give 


CAUSES  OF  DEATH  AFTER  OPERATION  185 

him  camphorated  oil  (up  to  4  to  5  c.c.  may  be  given  intravenously), 
atropin  or  digitalis  hypodermically.  It  is  improbable  that  saline 
solution  intravenously  or  transfusion  of  blood  will  be  of  value  unless 
there  has  been  hemorrhage.  The  measures  mentioned  (heat,  stimu- 
lants, transfusion)  will  be  effective  in  an  hour  or  so  if  hemorrhage 
is  the  main  factor  present.  When  there  is  a  severe  mangling  injury 
no  further  delay,  unless  the  patient  is  actually  moribund,  should  be 
permitted,  but  prompt  local  treatment  (excision,  amputation)  should 
be  instituted,  as  it  may  be  the  only  means  of  saving  the  patient's  life. 
It  is  possible  that  antitoxic  sera  may  some  day  be  available  for  shock. 

It  is  important  to  determine  whether  serious  symptoms  occurring 
during  an  operation  are  from  shock  or  from  acute  dilatation  of  the 
heart.  In  the  latter  condition,  which  may  arise  without  any  recogniz- 
able cause  for  shock,  the  head  should  be  kept  high,  and,  if  this  does 
not  relieve,  the  patient  should  be  bled,  and  in  extreme  cases  the  right 
ventricle  may  be  punctured.  Artificial  respiration  and  massage  of  the 
heart  (p.  269)  should  be  persisted  in  for  fifteen  or  twenty  minutes. 

Treatment  of  Traumatic  Delirium  and  Delirium  Tremens. — If  the 
patient  is  not  too  violent,  attempts  should  be  made  to  dilute  the 
toxins  in  the  blood  by  the  use  of  saline  solution,  by  rectum,  hypoder- 
mically, or  even  intravenously.  Lumbar  puncture  sometimes  aborts 
the  disease.  In  any  case  the  patient  should  be  isolated,  to  avoid  the 
mutually  exciting  effect  of  other  patients.  Catharsis  will  aid  elimi- 
nation of  toxins.  Sedatives  and  hypnotics  should  be  freely  employed, 
especially  veronal,  and  paraldehyde.  Sleep  should  be  obtained  at 
all  hazards,  but  morphin,  hyoscin,  chloral,  and  the  bromides  increase 
the  mortality,  and  are  much  less  effective  than  veronal  and  paralde- 
hyde (Ranson  and  Scott,  1911).  R.  S.  Hooker,  however,  gives  chloral 
in  large  doses,  hourly,  until  sleep  is  obtained.  Measures  must  be 
taken  to  prevent  the  patient  from  injuring  himself,  strapping  him  to 
the  bed  if  necessary,  and  never  leaving  him  unguarded  by  a  nurse 
or  orderly  strong  enough  to  control  his  actions.  Liquid  diet  should 
be  taken  in  moderation,  but  the  more  water  that  can  be  absorbed 
the  better.  Ranson  and  Scott  urge  the  use  of  ergot  (4  c.c.  of  fluid- 
extract  every  four  hours)  as  preventative  of  cerebral  edema  and  as  a 
general  circulatory  stimulant.  No  alcohol  should  be  given  to  patients 
with  alcoholic  delirium;  though  Ranson  and  Scott  urge  its  admini- 
stration at  least  in  the  first  stage  of  the  affection,  and  though  it  may 
be  used  as  a  prophylactic  where  the  development  of  delirium  tremens 
is  feared,  yet  all  surgeons  of  large  experience  in  accident  wards  find 
that  immediate  and  absolute  withdraival  of  alcohol  from  patients  with 
delirium  tremens  both  shortens  the  disease  and  decreases  the  mortality. 
In  traumatic  delirium  from  burns,  etc.,  in  which  there  is  clear  evidence 
that  no  element  of  delirium  tremens  is  present,  but  in  which  delirium 
is  due  chiefly  to  asthenia,  the  moderate  use  of  alcohol  frequently 
hastens  convalescence. 

Causes  of  Death  after  Operation. — As  operations  always  involve  the 
infliction  of  wounds,  this  seems  a  suitable  place  to  consider  the  causes 


186  INJURIES  AND   THEIR  EFFECTS 

of  death  after  operation.  Certain  of  these  causes  are  more  or  less 
avoidable;  such  are  shock,  hemorrhage,  pneumonia,  acidosis  and  sepsis. 
Others  usually  seem  unavoidable,  especially  myocarditis,  embolism, 
status  lymphaticus,  heat  prostration,  and  conditions  previously 
present  which  the  operation  could  not  remove  or  which  it  has  inevit- 
ably made  worse.  Among  the  latter  may  be  mentioned  various  forms 
of  sepsis  (peritonitis,  pyemia,  etc.),  curable  only  by  removal  of  the 
original  focus  and  the  institution  of  drainage,  but  which  these  meas- 
ures, though  judiciously  and  skilfully  executed,  nevertheless  fail  to 
relieve;  asthenia  from  preexisting  shock  or  hemorrhage,  death  being 
certain  without  operation,  but  a  fighting  chance  of  recovery  existing 
after  prompt  operation;  and  preexisting  disease  of  the  kidneys  or 
other  organs  when  operation  is  undertaken  as  the  only  means  of 
cure.  The  conscientious  surgeon  will  never,  therefore,  blithely  assure 
his  patient  that  any  operation  is  entirely  devoid  of  risk,  as  these 
calamitous  deaths  frequently  occur  when  least  expected. 

Shock. — See  p.  181. 

Hemorrhage. — The  importance  of  preventing  loss  of  blood  during 
operations  cannot  be  overestimated;  and,  fortunately,  gross  and 
sudden  hemorrhages  usually  can  be  prevented,  for  it  is  these  which 
are  much  more  lethal  than  the  slight  ooze  throughout  the  operation 
which  sometimes  is  unavoidable.  But  even  though  quite  large 
amounts  of  blood  may  be  lost  gradually  without  producing  immediate 
and  noticeable  effects,  it  is  much  better  for  the  surgeon  to  go  about 
his  work  deliberately,  clamping  or  tying  bleeding  vessels  as  he  goes, 
than  to  try  to  hurry  along  and  by  his  very  haste  making  less  speed 
from  having  continually  to  return  and  pick  up  vessels  which  might 
have  been  caught  with  more  effect  when  first  divided,  and  thus 
subject  his  patient  not  only  to  the  unnecessary  if  gradual  loss  of 
blood,  but  also  to  a  needlessly  prolonged  operation,  and  to  unneces- 
sary tissue  traumatism  from  repeated  sponging  and  search  for  the 
bleeding  points. 

In  addition  to  this  primary  hemorrhage  which  occurs  at  the  time  of 
operation,  surgeons  recognize  an  intermediary,  consecutive,  or  reac- 
tionary hemorrhage,  which  occurs  after  recovery  from  the  anesthetic 
or  the  shock  of  operation,  due  to  the  reestablishment  of  the  normal 
circulation  and  blood-pressure,  causing  bleeding  from  vessels  which 
escaped  notice  at  the  time  of  operation  owing  to  their  collapsed 
condition;  and  a  secondary  hemorrhage,  which  occurs  any  time  between 
the  occurrence  of  reaction  and  the  ultimate  healing  of  the  wound. 
Secondary  hemorrhage  is  due  usually  to  separation  of  ligatures 
(1)  from  their  having  been  insecurely  applied  at  first;  (2)  to  their 
premature  absorption;  or  (3)  to  ulceration  of  the  vessel  walls  at  the 
site  of  ligation;  occasionally  it  is  due  (4)  to  sloughing  of  a  vessel  at 
another  point  in  the  wound. 

The  treatment  of  hemorrhage  is  discussed  at  p.  260. 

Pneumonia. — Careful  examination  of  the  lungs  always  should  be 
made  before  undertaking  any  operation,  especially  under  a  general 


CAUSES  OF  DEATH  AFTER  OPERATION  187 

anesthetic.  If  bronchitis  or  pneumonia  already  exists  and  the  oper- 
ation cannot  possibly  be  postponed,  as  in  the  case  of  strangulated 
hernia,  local  or  spinal  anesthesia  should  be  employed.  To  prevent 
the  development  of  pulmonary  complications,  a  general  anesthetic 
must  be  given  with  care,  guarding  against  choking,  secretion  of  mucus, 
and  inspiration  of  vomited  particles;  and  pains  must  be  taken  not  to 
expose  the  patient  to  chilling,  draughts,  etc.,  either  during  operation 
or  while  recovering  from  the  anesthetic.  After  an  operation,  patients, 
especially  if  aged,  should  not  be  kept  flat  on  the  back  long,  being 
turned  from  side  to  side  at  suitable  intervals  to  guard  against  the 
development  of  hypostatic  congestion;  deep  breathing  should  be 
enjoined  periodically;  and  they  should  be  allowed  to  sit  up  or  to 
leave  the  bed  so  soon  as  the  condition  of  the  wound  permits.  Under 
the  term  massive  collapse  of  the  lung,  W.  Pasteur  (1911)  describes  a 
condition  often  mistaken  for  pneumonia,  but  due  to  inhibition  of  dia- 
phragmatic action  from  operations  in  the  upper  abdominal  or  renal 
regions. 

Sepsis. — In  operations  on  previously  aseptic  structures,  sepsis  can 
and  should  be  prevented.  Whenever  it  occurs  under  such  circum- 
stances, the  surgeon  should  seriously  endeavor  to  detect  the  fault 
in  his  technique,  in  order  that  a  similar  calamity  may  not  occur 
again.  In  operations  on  already  infected  parts,  it  will  not  always 
be  possible  to  prevent  infection  from  spreading  further,  or  from 
becoming  more  virulent  even  if  still  localized;  but  by  strict  adherence 
to  antiseptic  methods,  unfavorable  results  might  be  made  much  less 
frequent  than  they  are. 

Myocarditis. — "Heart  failure"  usually  is  an  unavoidable  cause  of 
death;  detection  of  the  lesion  before  operation  is  frequently  difficult, 
and  even  skilled  physicians  occasionally  err  in  estimating  the  ability 
of  an  evidently  diseased  heart  to  withstand  the  strain  of  operation. 
The  choice  of  anesthetic,  the  position  of  the  patient  during  operation, 
avoidance  of  causes  of  cardiac  collapse  and  of  shock,  the  rapidity 
and  extent  of  the  operation  itself,  all  deserve  to  be  considered  more 
attentively  than  usual  in  such  patients. 

Embolism. — Under  the  term  "secondary  or  insidious  shock"  (p. 
273)  was  formerly  described  a  condition  which  is  now  popularly 
known  as  "pulmonary  embolism."  From  some  chemical  change 
(bacterial  or  aseptic)  in  the  blood,  it  becomes  more  prone  to  clot, 
and  at  varying  periods  after  operation,  but  usually  not  until  con- 
valescence seems  assured,  a  portion  of  a  thrombus,  formed  at  or  near 
the  seat  of  operation,  is  detached,  is  carried  to  the  right  heart,  and 
thence  to  the  pulmonary  arteries,  where  it  may  lodge;  or,  passing 
through,  may  cause  pulmonary  infarction.  The  symptoms  are  sudden 
dyspnea,  cyanosis,  precordial  pain,  collapse,  and  rapid,  perhaps 
immediate,  death.  Busch  (1909)  studied  twenty-two  deaths  after 
operation,  presenting  symptoms  usually  ascribed  to  pulmonary 
embolism;  twelve  of  these  patients  died  with  great  suddenness,  no 
preliminary    symptoms   of    any    kind   existing;    while    in    ten    death 


1SS  INJURIES  AND   THEIR  EFFECTS 

occurred  at  periods  varying  from  ten  minutes  to  three  and  one-half 
hours  after  onset  of  the  symptoms.  These  ten  patients  all  came 
to  autopsy,  and  in  only  five  was  a  pulmonary  embolus  or  infarction 
found,  the  five  others  having  died  from  myocarditis.  The  diagnosis, 
therefore,  is  not  always  easy. 

Treatment.  -The  treatment  is  purely  symptomatic,  including 
inhalations  of  ammonia,  and  the  hypodermic  use  of  atropin,  oil  of 
camphor,  etc.  Trendelenburg  (1908)  proposed  arteriotomy  of  the 
pulmonary  artery,  by  opening  the  pericardium,  with  removal  of 
the  clot;  he  adopted  the  operation  in  one  case,  his  patient  living 
until  the  next  day,  while  Siever's  patient  (1908)  lived  fifteen  hours. 
As  death  frequently  occurs  with  great  suddenness,  giving  no  oppor- 
tunity for  treatment  of  any  kind;  and  as  in  other  cases  recovery 
under  expectant  treatment,  though  rare,  is  not  unknown;  and  as  the 
diagnosis  between  myocarditis  and  embolism  is  often  impossible,  I 
think  Trendelenburg's  operation  should  be  regarded  at  present  more 
in  the  light  of  a  curiosity  than  as  a  practice  for  habitual  employment. 

Fat-embolism. — Fat-embolism  occasionally  occurs  after  injuries  of 
or  operations  on  bones.  The  symptoms  and  treatment  resemble 
those  of  ordinary  pulmonary  embolism;  lipuria  is  not  pathogno- 
monic, though  suggestive,  and  it  may  exist  in  cases  of  simple  fracture 
without  evidence  of  embolism. 

Status  Lymphaticus. — This  term  is  used  to  describe  a  condition 
in  which  there  exists  widespread  enlargement  of  lymphoid  tissue 
in  all  portions  of  the  body — naso-pharyngeal  "adenoids,"  cervical 
"adenitis,"  hypertrophy  or  hyperplasia  of  the  bronchial  and  mesen- 
teric lymph  nodes,  and  of  the  thymus  gland.  It  is  most  frequent 
in  rachitic  children,  and  subjects  of  it  are  liable  to  sudden  death  at 
any  time,  even  during  natural  sleep  (Blumer,  1903).  The  true  cause 
of  these  deaths  is  not  known,  but  is  probably  to  be  classed  as  an 
"auto-intoxication;"  death  almost  certainly  is  not  due  to  acute 
enlargement  of  the  thymus  gland  causing  asphyxia  from  pressure 
on  the  trachea.  Unfortunately  the  existence  of  the  condition  is 
rarely  if  ever  recognized  until  death  occurs.  Undoubtedly  some 
deaths  charged  to  the  anesthetic  really  are  due  to  the  status  lymph- 
aticus. Death  may  occur  while  the  patient  is  under  the  anesthetic, 
or,  as  is  more  often  the  case,  a  few  hours  later,  with  symptoms  of 
dyspnea,  rapid,  feeble  pulse,  high  temperature,  and  restlessness,  but 
with  no  evidence  of  traumatic  delirium. 

Acidosis. — Acidosis  is  the  name  given  to  an  acid  intoxication  similar 
to  that  which  sometimes  occurs  in  diabetics,  and  which  may  be  a 
cause  of  death  after  operation.  It  is  predisposed  to  by  starvation, 
by  deprivation  of  fluids  and  carbohydrates.  Its  development  is  to 
be  feared  in  homesick  children  who  cry  all  the  time  and  will  not  eat 
after  entering  the  hospital  for  operation;  also  in  cases  of  advanced 
sepsis  (peritonitis,  puerperal  septicemia).  The  anesthetic,  not  the 
operation,  precipitates  the  attack.  Chloroform  is  especially  to  be 
avoided.     The  symptoms  resemble  those  enumerated  above  as  occur- 


CAUSES  OF  DEATH  AFTER  OPERATION  189 

ring  in  status  lymphaticus;  there  is  acetone  and  in  advanced  cases 
diacetic  acid  in  the  urine.  Treatment  consists  in  saturating  the 
patient  with  alkalies.  Sodium  bicarbonate  should  be  eaten  liberally; 
if  there  is  vomiting,  wash  the  stomach  and  give  the  alkali  intra- 
venously, one  or  two  liters  of  a  3  per  cent,  solution.  Sweating,  as  in 
diabetic  or  uremic  coma,  is  indicated  to  aid  elimination. 

Heat  Prostration. — Heat  prostration  occasionally  causes  a  post- 
operative death.  The  symptoms  and  treatment  are  the  same  as 
for  heat  prostration  in  other  patients.  It  is  well  to  postpone  all 
operations  but  those  of  immediate  necessity  during  the  prevalence 
of  extremely  hot  weather. 


CHAPTER   VII. 
GUNSHOT  WOUNDS. 

WnEN  a  soldier  in  the  front  lines  is  wounded,  he  is  supposed  to 
apply  to  his  wound  the  dressing  in  his  first  aid  packet;  but  in  con- 
ditions of  modern  warfare  this  is  not  of  much  use  except  for  bullet 
wounds;  other  wounds  are  too  large,  and  even  if  smaller  than  the 
dressing,  the  latter  does  not  remain  aseptic  during  application;  nor  is 
the  underlying  wound  aseptic  even  if  covered.  Then  the  soldier  keeps 
under  cover  of  the  trenches  or  shell-holes,  and  if  artillery  fire  is  not 
too  intense,  and  if  he  is  able,  finds  his  own  way  back  to  the  First  Aid 
Station  (Post  de  Secours  of  the  French).  Otherwise  he  lies  where  he 
fell  until  found,  usually  the  following  night,  by  the  litter-bearers  who 
have  come  out  for  the  purpose  from  the  First  Aid  Station.  On  arrival 
at  the  latter  (about  0.5  to  1  kilometer1  distant),  the  clothing  is  cut 
away  from  the  wound  area,  and  this  is  cleansed  with  any  available 
antiseptic,  a  dry  dressing  is  applied,  antitetanic  serum,  and,  if  indi- 
cated, morphin  are  given,  and  a  diagnosis  tag  is  attached.  Trans- 
port splints  for  fractures  are  also  applied  here;  indeed,  in  many  cases 
these  have  been  carried  forward  and  applied  in  the  trenches  or  over 
the  top  before  evacuation  is  even  commenced.  At  the  First  Aid 
Station  also  the  patient  is  fed  and  rested.  He  may  have  to  remain 
here  until  nightfall  before  the  next  step  in  evacuation.  From  the 
First  Aid  Station  to  the  most  advanced  point  that  can  be  reached  by 
motor  ambulances  (usually  a  distance  of  4  to  8  kilometers),  where 
the  Field  Hospital  is  established,  the  wounded  are  carried  through  the 
evacuation  trench  on  hand  litters,  by  relays  of  bearers.  This  journey 
may  take  from  one  to  three  hours.  In  some  sectors  it  is  possible 
to  employ  light  motor  ambulances  for  this  journey. 

Field  Hospital. — At  the  Field  Hospital  it  is  expected  that  the  very 
seriously  wounded  (the  worst  head,  thoracic  and  abdominal  injuries 
and  cases  of  acute  hemorrhage  which  has  been  temporarily  controlled 
by  tourniquet  or  tampon)  will  be  retained,  and  emergency  operations 
done;  but  often  it  is  impossible  to  keep  such  patients,  and  they  have 
to  be  sent  on  with  the  main  bulk  of  the  wounded,  by  motor  ambu- 
lances to  the  nearest  railhead,  where  the  Evacuation  Hospital  (the 
French  H.  O.  E.,  the  English  C.  C.  S.)  is  established. 

Evacuation  Hospital. — The  Evacuation  Hospital,  of  500  to  1000 
beds  capacity,  usually  is  established  from  15  to  25  kilos  back  of  the 

1A  kilometer  is  about  0.6  mile;  to  reduce  from  kilometers  to  miles,  multiply 
by  6  and  move  the  decimal  point  one  space  to  the  left:     20  kilos   =    12  miles; 
2  kilos  =  1.2  miles. 
(190) 


EVACUATION  HOSPITAL 


191 


front  trenches.1     It  is  fully  equipped  to  do  all  kinds  of  surgery.     The 
wounded  reach  it  from  six  to  thirty  hours  after  injury,  and  in  quiet 


Fig.  130. — Diagram  of  battlefield  and  evacuation  of  wounded  A.  E.  F. 

1  Mobile  Units,  corresponding  to  the  Auto.  Chir.  of  the  French  (Ambulance 
Chirurgicale  Automobile),  which  are  in  every  way  as  well  equipped  as  the  Evacua- 
tion Hospitals,  may  be  established  temporarily  even  nearer  the  front.     All  these 


192  GUNSHOT  WOUNDS 

sectors  may  be  hospitalized  until  nearly  convalescent.  In  active 
sectors  all  who  are  not  strictly  intransportable  are  evacuated  to  the 
Bases  as  soon  after  operation  as  accommodations  can  be  found  for 
them  on  the  Hospital  Trains.  The  latter,  well  equipped  for  nursing 
and  feeding  the  patients,  reach  their  bases  within  twelve  to  forty-eight 
hours:  thus  in  the  most  favorable  contingencies  a  wounded  soldier 
may  reach  the  Base  within  twenty-four  hours  of  the  time  of  injury; 
but  the  average  time  required  is  three  to  four  days.  When  possible 
the  slightly  wounded  should  be  segregated  at  the  Evacuation  Hospital, 
and  sent  to  a  hospital  center  in  the  intermediate  zone,  whence  they 
may  be  returned  to  the  front  when  recovered  without  ever  reaching 
the  Base. 

Base  Hospital. — The  Base  Hospitals,  from  50  to  100  kilometers  or 
more  from  the  battle  front,  and  with  a  capacity  of  from  1000  to  3000 
beds  each,  are  equipped,  so  far  as  exigencies  of  wartime  permit,  like 
the  best  metropolitan  civilian  hospitals,  and  the  treatment  is  such  as 
can  be  given  under  these  circumstances. 

Missiles.  —  Gunshot  wounds  are  those  produced  by  missiles  pro- 
jected by  the  explosive  action  of  gunpowder.  The  missiles  include 
the  various  projectiles  from  artillery  (chiefly  shells  and  shrapnel); 
bombs  from  airplanes;  bullets  from  machine  guns  and  from  small  arms 
(muskets,  rifles,  revolvers,  pistols,  etc.);  hand  grenade  fragments;  as 
well  as  small  shot  from  shotguns.  Shells  and  bombs  are  directed  rather 
against  defences,  lines  of  communication,  ammunition  dumps,  etc., 
than  against  the  soldiers  on  guard,  and  these  rarely  are  injured  except 
by  fragments  of  such  large  missiles.  Cannister  and  shrapnel  are  much 
alike,  being  composed  of  a  collection  of  small  missiles  within  a  steel 
casing;  but  cannister  explodes  as  it  is  discharged  from  the  gun,  while 
shrapnel  contains  an  explosive  in  its  center,  with  a  time  fuse,  and  is 
exploded  only  when  the  time  fuse  is  consumed.  Both  shrapnel 
(which  is  filled  with  round  lead  bullets),  and  cannister  (filled  with 
missiles  of  all  shapes  and  sizes)  are  used  only  at  close  range,  the  latter 
scarcely  ever,  and  the  former  very  seldom,  in  modern  warfare.  A 
shell  is  a  hollow  steel  cylinder  with  conoidal  nose,  from  75  to  150  or 
even  320  mm.  in  diameter,  containing  a  charge  of  high  explosive;  it 
bursts  on  impact  or  by  a  time  fuse,  and  each  fragment  may  set  in 
motion  other  missiles,  by  striking  and  shattering  rocks,  trees,  houses, 
etc.  Bombs  dropped  by  avions  are  similar  to  shells  in  size  and  con- 
struction, and  explode  on  impact;  grenades,  thrown  by  hand  in  close 
combat,  resemble  small  shells.  Gas  shells  are  also  employed  in  modern 
warfare ;  there  are  mustard  gas  shells,  which  cause  burns  of  the  surfaces 
of  the  body  (p.  178);  and  poison  shells,  which  on  bursting  disperse 
poison  gases  acting  chiefly  on  the  respiratory  tract,  and  cause,  if  not 

sanitary  formations  make  use  of  existing  buildings,  when  available.  The  First 
Aid  Stations  usually  are  in  dug-outs,  underground,  or  in  the  sides  of  hills,  for 
protection  from  shell-fire.  Auto.  Chirs.  and  Evacuation  Hospitals  are  not  usually 
exposed  to  shell-fire,  and  depend  for  protection  against  bombs  of  avions  on  being 
distinctly  marked  as  Hospitals  by  immense  red  crosses  laid  out  in  broken  bricks, 
etc.,   in   the   surrounding  fields. 


GENERAL  NATURE  OF  GUNSHOT  WOUNDS 


193 


immediate  death  from  suffocation,  at  least  very  severe  pulmonary 
complications. 

The  modem  conoidal  bullets  (Fig.  131)  are  projected  from  rifled 
barrels.  The  rifling  imparts  to  the  missile  a  rotatory  motion  or  spin, 
which  approximates  3000  revolutions  per  second  on  its  discharge,  at 
which  instant  its  velocity  is  over  800  meters  (nearly  2700  feet)  per 
second  (initial  velocity).  The  Mauser  bullet  still  in  use  in  the  U.  S. 
Army  is  30  caliber  (i.  e.,  0.3  inch — about  8  mm. — in  diameter)  and 
1.08  inch  (about  28  mm.)  long;  it  consists  of  a  core  of  lead  and  tin 
composition  inclosed  in  a  jacket  of  copper  and  nickel,  and  weighs 
about  10  grams.  The  German  Mauser  bullet  is  28  mm.  long,  7  mm. 
in  diameter,  and  weighs  10  grams.  The  high  velocity  imparted  to  the 
modern  bullet  tends  to  make  its  trajectory  (line  of  flight)  more  nearly 
horizontal,  thus  increasing  the  danger  zone.  When  fired  horizontally 
("point  blank")  the  danger  zone  embraces  the  entire  trajectory  of 
the  bullet,  which  under  such  circum stances  is  about  700  meters  in 


12                                                     3  4 

Fig.   131. — Evolution  of  the  bullet.      1,  old  rounded  musket  ball;  2,  Minie  bullet; 

3,  0.45-caliber  Springfield;    4,   0.30-caliber  jacketed   Springfield,    model  1905.     All    of 
natural  size.     (.Bryant  and  Buck.) 


length;  when  aimed  at  a  greater  distance,  the  shot  is  fired  into  the  air, 
the  trajectory  is  a  parabolic  curve,  and  the  danger  zone  is  removed  to 
the  area  within  which  the  bullet  is  liable  to  strike  earth.  The  rotatory 
motion  and  high  velocity  combined,  tend  to  lessen  the  bullet's  dip, 
thus  enabling  it  to  strike  more  nearly  end-on;  while  both  factors 
markedly  increase  its  penetrating  power.  The  range  of  the  bullet  is 
nearly  two  miles,  being  fairly  accurate  up  to  one  mile.  At  short 
range,  and  at  long  range,  it  wobbles,  the  period  of  steady  flight  being 
comparable  to  the  period  when  a  boy's  spinning  top  is  "asleep." 

General  Nature  of  Gunshot  Wounds. — Bullet  wounds  formerly 
comprised  nearly  90  per  cent,  of  those  seen  in  war,  and  form  almost 
the  only  variety  of  gunshot  wounds  encountered  in  civil  life,  with 
the  exception  of  occasional  wounds  from  small-shot  or  from  wadding 
out  of  blank  catridges.  In  the  German  War,  however,  bullet  wounds 
formed  less  than  half  of  those  seen,  the  majority  being  due  to  shell 
fire.  (Early  in  the  war,  before  the  complete  development  of  the 
machine  gun,  bullet  wounds  formed  only  15  per  cent,  of  the  total.) 
13 


104 


GUNSHOT   WOUNDS 


Missiles  penetrate  or  perforate  the  body,  or  cause  superficial  "gutter" 
or  tangential  wounds.  If  they  merely  penetrate,  there  is  only  a 
wound  of  entrance;  if  they  perforate  there  is  also  a  wound  of  exit1  (Fig. 
1:12).  But  the  wound  of  entrance  may  be  within  the  mouth,  or  even 
within  the  anus  or  external  auditory  meatus. 

Bullet  Wounds. — If  the  bullet   is  fired  at  close  range   (usually  not 
over  1  meter)  there  will  be  powder  marks  around  the  wound  of  entrance. 
The  wound  of  exit  is  usually,  especially  in  civil  life,  larger  than  the 
wound  of  entrance,  and  its  margins  may  be  somewhat  everted.     If 
the  bullet  was  fired  at  close  range,  or  if  nearly 
spent,  or  if  deformed  by  striking  elsewhere 
first  (wound  by  ricochet),  the  wround  of  exit  may 
be  very  ragged  or  even  explosive,  while  even 
the  wound  of  entrance  may  be  gaping  (Fig.  136). 
These  characters  of  the  wounds  are  due  to  the 
wobble  of  the  bullet,  to  its  carrying  foreign  par- 
ticles or  pieces  of  flesh  and  bone  before  it  into 
and  out  of  the  wound,  to  its  deformed  state,  or 
to  its  emerging  sideways  (no  longer  end-on). 
The  wound    of    entrance    sometimes    seems 
smaller  than  the  missile  by  which  it  was  pro- 
duced, from  the  elasticity  of  the  skin.     If  two 
bullets  enter  by  the  same  wound,  one  may  pass 
through  and  the  other  lodge;  or  they  may 
emerge  by  the  same  or  by  different  wounds; 
and  two  bullets  may  enter  by  different  wounds 
and  emerge  by  the  same  wound  of  exit.    One 
bullet  may  traverse  successively  various  parts 
of  the  body,  making  wounds  of  entrance  and 
exit    in    both   lower  or   upper   limbs,  or  in  a 
limb  and  the  trunk;  or  if  the  limb  is  acutely 
flexed,  traversing  the  same  limb  twice.     The 
tract  of  the  bullet  forms  a  sinus  which  heals 
by   the   ordinary    processes  of    repair.      The 
smaller  the  caliber  of  the  bullet  the  less  likely 
is  sloughing  to  occur;  wounds  by  bullets  of  0.22 
caliber  frequently  heal  without  infection  evenin 
civil  life;  those  by  bullets  of  0.35  caliber  or  over 
frequently  suppurate  throughout  their  extent. 
At  close  range  (up  to  400  meters)  the  modern  military  bullet  has 
what  is  known  as  an  explosive  effect;  that  is  to  say,  any  marked  resist- 
ance causes  its  energy  to  be  transmitted  into  the  surrounding  tissues. 
The  more  resistant  the  tissues,  the  more  marked  is  the  explosive  effect. 
This  is  particularly  noticeable  in  bone:   if  the  spongy,  expanded  epi- 
physes are  struck,  there  is  little  resistance  offered  and  a  grooved  or 
tunnelled  wound  will  be  produced  (Fig.  133) ;  wrhereas  if  the  hard  brittle 

1  Abbreviated  by  the  French  as  O.E.  (orifice  of  entry)  and  O.S.  (orifice  of  sortie, 
or  exit). 


It 

ii  w 


Fig.  132.— 0.38-caliber 
bullet  wound  in  right  calf. 
Wound  of  entrance  on 
outer  side;  wound  of  exit 
on  median  side.  Five  days 
after  injury.  Episcopal 
Hospital. 


BULLET   WOl'SDS 


195 


diaphysis  is  struck,  the  bone  will  be 
shattered  (Fig.  134).  Fluid  saturated 
or  fluid  containing  organs  offer  extreme 
resistance  to  bullets  because  of  their  lack 
of  compressibility;  the  brain,  the  liver 
land  the  hollow  viscera  (if  distended  with 
liquid  or  semisolid  food)  afford  notable 
examples  of  this  explosive  action,  which  is 
due  to  the  missile's  high  initial  velocity. 
Larger  missiles  (as  the  old  round  shot) 
with  much  lower  velocity,  even  when 
almost  spent,  may  have  an  equally  de- 
structive action.1 

The  bullet  wounds  encountered  in  civil 
life  (suicide,  homicide,  etc.),  as  a  rule,  are 
not  produced  by  modern  military  bullets, 
but  by  softer,  unjacketed  bullets  (Minie 
or  Springfield)  of  low  velocity  (about  220 
meters    per   second) ;  the   caliber  varies 

1  These  facts  are  concisely  expressed  in  the 
physical  formula  M  =  mv;  that  is,  the  momen- 
tum equals  the  product  of  the  mass  by  the 
velocity,  and  if  either  the  mass  (as  in  the  larger 
missiles)  or  the  velocity  (as  in  the  modern 
military  bullet  I  lie  sufficiently  great,  the  mo- 
mentum of  the  projectile,  -and  hence  its  de- 
structive action,  will  be  correspondingly  great. 


Fig.  133. — Cancellous  bone  perforated  l>v  bullet. 
(After  Helferich.) 


— Compact  boneshat- 
bullet.      'After    Hel- 


L96 


GUNSHOT   WOUNDS 


Fig.  135.— Soft  bullet  de- 
formed (mushroomed)  by  strik 
ing  bone  end-on.  From  i 
patient  in  the  Episcopal  Hos 
pital. 


from  0.22  to  0.40  or  0.45  (5.5  to  11.25  mm.)  but  is  usually  large.     As 
in  civil   life  the  bullet  is  softer,  larger,   and  slower,  it  is    more  easily 

deflected  and  deformed,  and  almost  invari- 
ably lodges  in  the  patient's  body;  the  wound 
is  less  clean-cut,  more  lacerated  and  con- 
tused, than  that  produced  by  the  military 
bullet  (Fig.  135.)  In  war  it  is  rather  ex- 
ceptional for  the  bullet  (unless  nearly  spent) 
to  lodge  in  the  patient's  body;  and  owing  to 
the  greater  velocity,  the  direct  impact,  and 
the  rectilinear  course  of  the  bullet  through 
the  body,  and  its  subsequent  absence  from 
the  wound,  infection  is  not  usual. 

Wounds  by  Shell  Fragments,  as  already 
noted,  usually  are  very  severe.  In  civil  life 
such  wounds  are  encountered  only  in  blast- 
ing accidents,  explosions,  etc.  The  larger 
fragments  of  the  shell,  or  the  rocks,  beams, 
trees,  etc.,  projected  by  the  explosion,  may 
carry  a  limb  completely  away,  blow  the  head 
off,  or  actually  destroy  a  large  portion  of  the  trunk.  In  such  cases 
death  may  be  immediate  or  occur  before  aid  can  be  rendered.  Smaller 
fragments,  the  average  size  being  about  10 
to  15  mm.  in  diameter,  may  be  driven  into 
the  tissues  in  all  directions  and  to  all  depths, 
each  one  carrying  along  with  it  deadly  germs 
( Fig.  137.)  These  fragments  are  much  more 
apt  to  lodge  than  are  bullets.  In  the  German 
War  no  such  wounds  could  be  considered 
clean,  unless  produced  by  fragments  of  ex- 
treme minuteness  (2  or  3  mm.  in  diameter). 
In  almost  every  instance  foreign  materials, 
especially  fragments  of  clothing,  are  carried 
into  the  wound  by  the  shell  fragments,  and 
are  left  in  the  tissues  even  when  the  shell 
fragment  itself  fails  to  lodge.  In  such  cases, 
apparently  innocent  on  the  surface,  debride- 
ment shows  the  muscular  tissues  pulpefied 
to  an  incredible  extent,  forming  an  excep- 
tionally favorable  nidus  for  bacterial  growth. 
Such  closed  wounds  (Fig.  138)  are  in  many 
respects  more  to  be  dreaded  than  the  im- 
mense open  wounds  where  the  damage  is 
clearly  apparent. 

The   tremendous  concussion  in  the   sur- 
rounding air  produced  by  shell  explosion  may 

knock  a  group  of  soldiers  down  or  even  cause  them  to  be  projected 
into  the  air  for  some  distance,  resulting  in  wounds  from  their  impact 


Fig.  136.— Bullet  wound  of 
left  shoulder  region,  explosive 
exit.  (Auto-Chir.  6,  French 
Army.) 


SMALL-SHOT  WOUNDS 


197 


against  surrounding  objects.  It  has  even  been  held  that  the  concussion 
alone  without  direct  trauma  may  produce  serious  lesions  of  the  internal 
organs,  particularly  of  the  brain  and  spinal  cord;  but  this  suppo- 
sition lacks  confirmation. 


Fig.  137. — Multiple  wounds  by  shell  fragments.  Gas  gangrene  of  right  leg  and  thigh; 
compound  fracture  of  right  fibula;  amputation  below  hip.  Compound  fracture  of  left 
patella  into  knee-joint;  excision  of  knee.  Debridement  of  other  wounds.  Recovery. 
(Auto-Chir.  6,  French  Army.) 

Small-shot  Wounds  are  occasionally  seen  in  civil  life.  If  fired  at 
close  range,  small  shot  produces  great  damage,  the  wounds  resembling 
those  caused  by  artillery  projectiles  (Fig.  139).  Fingers,  toes  and 
parts  of  the  hand  or  foot  are  frequently  blown  off.  If  at  longer  range, 
the  shot  scatters,  there  is  no  powder  burn,  and  comparatively  little 
damage  may  be  done,  particularly  in  the  case  of  bird-shot.  Of  course, 
if  the  eye  be  struck,  or  an  important  nerve  or  bloodvessel  injured, 
the  consequences  may  be  very  serious  from  the  impact  even  of  one  or 
two  shot.  It  is  seldom  necessary  to  extract  all  these  small  shot.  If 
the  part  be  treated  as  for  a  contused  wound  it  usually  does  well. 


1<)S 


GUNSHOT   WOUNDS 


Wounds  from  Blank  Cartridges  scarcely   require  separate    mention. 
Thev  occur  in  this  country  chiefly  about  the  Fourth  of  July.     If  the 


Fig.  138. — Subcutaneous  pulpefaction  of  muscles  in  shell  wound  necessitating  excision 
of  entire  thickness  of  the  muscle  for  15  to  25  cm.  longitudinally. 


Fig.  139. — -V-ray  of  small  shot  fracture  of  femur.     Death  from  shock  five  hours  after 
admission.     Esmarch  band  in  place.     Episcopal  Hospital. 


TREATMENT  OF  SMALL-SHOT  WOUNDS  199 

wadding  has  lodged,  it  should  be  extracted,  devitalized  tissue  should 
be  cut  away,  the  raw  surface  swabbed  with  iodin  (3  per  cent.),  and  the 
wound  dressed  antiseptically. 

Symptoms. — These  are  general  and  local.  Shod:  seldom  is  marked 
immediately  after  the  injury;  it  develops  only  after  exposure,  unless 
a  vital  organ  is  wounded  or  unless  the  wound  is  very  extensive.  In 
the  heat  of  battle  a  soldier  may  be  scarcely  aware  that  he  is  wounded 
until  he  feels  the  trickling  blood.  Traumatic  delirium  is  rare  and 
usually  not  marked,  being  manifested  by  extreme  talkativeness  and 
sometimes  by  hilarity.  Pain  from  bullet  wounds  rarely  is  great, 
usually  being  merely  a  stinging  sensation,  as  if  from  a  smart  blow  with 
a  whip.  Hemorrhage  seldom  is  profuse,  unless  from  a  bullet  wound 
of  a  large  bloodvessel,  and  it  is  more  likely  that  a  hematoma  will  form 
than  that  there  will  be  continued  external  bleeding.  Shell  frag- 
ments, even  when  large  bloodvessels  are  implicated,  very  seldom 
cause  much  hemorrhage,  owing  to  the  contused  nature  of  the  wound. 
Secondary  hemorrhage  (p.  2(U)  is  liable  to  occur  at  any  time  until 
sloughs  separate. 

Prognosis. — In  warfare  there  is  one  soldier  killed  for  every  four,  five, 
or  six  wounded  and  this  proportion  has  been  very  little  altered  by 
the  changes  in  military  equipment.  A  large  proportion  of  gunshot 
wounds  therefore,  seems  to  be  necessarily  fatal;  but  in  the  remaining 
cases  the  prognosis  depends  almost  entirely  upon  the  treatment.  By 
modern  methods  the  death-rate  has  been  reduced  to  5  or  10  per  cent. 
The  bullet  wounds  of  war  are  not  seriously  infected  of  themselves, 
and  if  kept  clean  the  resistance  of  the  patients  usually  is  sufficient 
to  ensure  a  good  result,  at  least  as  regards  life.  Wounds  by  shell 
fragments,  however,  have  been  uniformly  infected,  and  therefore  are 
more  disabling  than  those  by  bullets.  Injuries  of  the  trunk  are  more 
serious  than  those  of  the  extremities,  because  of  damage  to  viscera; 
but  they  are  also  less  frequent.  Injuries  to  the  extremities  involving 
bones,  joints  or  bloodvessels  are  more  serious  than  mere  flesh  wounds. 
The  positions  of  the  wounds  of  entrance  and  exit  frequently  will 
enable  the  surgeon  to  exclude  injury  of  important  structures.  Mul- 
tiple wounds,  even  when  each  wound  appears  insignificant,  usually 
prove  very  serious. 

Treatment. — As  soon  as  possible  after  injury  the  patient  should 
receive  hypodermically  500  units  (U.  S.)  of  antitetanic  serum.1  If 
the  wound  is  extensive  or  painful,  especially  if  there  is  a  fracture,  a 
large  dose  of  morphin  (16  to  32  mg.)  should  be  given.  This  is  done 
at  the  First  Aid  Station.  The  wound  area  is  also  exposed,  cleansed 
mechanically  so  far  as  possible  without  a  general  anesthetic,  its 
edges  wiped  with  any  available  antiseptic,  and  it  is  covered  with  dry 
sterile  gauze.     Transport  splints  (p.  204)  are  also  applied.     Then  the 

1  It  is  probable  that  in  future  wars  this  may  be  combined  with  a  serum  prophy- 
lactic against  gas  gangrene.  The  dose  of  antitetanic  serum  should  be  repeated 
at  the  time  of  any  secondary  operation. 


200  GUNSHOT  WOUNDS 

patienl  is  fed  and  allowed  to  rest  and  if  possible  to  sleep  until  evacua- 
tion to  ilif  Field  Hospital  becomes  possible. 

At  the  Field  Hospital  soiled  dressings  are  renewed,  splints  arc  read- 
justed, and  the  patients  arc  \\-(\.  Occasional  emergency  operations 
m;i\  be  demanded.  But  so  Par  as  possible  all  patients  are  evacuated 
by  ambulance  as  speedily  as  possible  to  the  Mobile  Units  or  Evacua- 
tion Hospitals.  Here  again  it  is  important  to  provide  for  the  patients' 
general  condition,  as  well  as  to  care  for  the  wounds.  The  patients  must 
be  bathed,  fed,  and  allowed  to.  sleep.  This  usually  is  possible  while 
awaiting  admission  to  the  operating  room.  Serious  cases  must  have 
precedence.  Badly  shocked  patients  are  sent  at  once  to  the  heating 
room,  where  necessary  measures  are  carried  out  by  shock  teams. 
Unfortunately  this  delays  resort  to  operation  and  increases  the  chances 
of  infect  ion.  A  general  sponge  hath  should  be  given  to  all  patients 
if  at  all  possible;  at  least  the  area  surrounding  the  wounds  should 
be  well  cleansed  mechanically  and  dry  shaved.  Soap  and  water 
should  not  be  used  on  the  wound  nor  on  adjacent  skin.  Splints 
should  not  be  removed  until  the  patient  is  on  the  operating  table 
and  anesthetized.  In  the  preparation  room,  or  elsewhere,  the  slightly 
wounded  should  be  segregated  and  sent  to  the  minor  operating  room, 
where  most  of  the  treatments  can  be  done  without  any  anesthetic 
or  under  primary  (p.  151)  or  local  anesthesia.  Such  operations  fall 
under  the  heading  of  what  the  French  describe  as  Nettoyage,  which 
implies  mechanical  cleansing  alone,  and  Epluchage,  which  means  the 
plucking  from  the  wound  of  all  foreign  substances.1  After  leaving  the 
preparation  room  all  patients  except  those  in  whom  such  an  examina- 
tion is  manifestly  superfluous,  should  pass  through  the  fluoroscopic 
room;  here  the  radiologists  localize  foreign  bodies — shell  fragments, 
bullets,  shrapnel  balls.  By  all  means  the  most  satisfactory  localiza- 
tions for  the  surgeon  as  well  as  most  rapidly  done  by  the  radiologist, 
are  those  where  the  foreign  body  is  indicated  as  being  of  certain 
dimensions,  at  a  certain  depth  under  a  near  point  marked  indelibly 
on  the  skin.  This  localization  is  found  both  more  accurate  and 
convenient  than  that  by  two  or  more  axes  intersecting  at  the  site  of 
the  foreign  body. 

From  the  fluoroscopic  room  the  patients  are  taken  to  the  operating 
rooms,  where  the  surgical  teams  (surgeon,  assistant,  anesthetist, 
nurse  and  two  orderlies)  work  in  shifts  from  eight  to  twelve  hours  at 
a  time.  Here  the  operations  consist  mostly  in  those  succinctly 
described  by  the  French  as  Debridement,  Excision  and  Extraction. 
Ether  is  the  most  satisfactory  anesthetic;  chloroform  is  particularly 
dangerous  in  those  who  have  been  "gassed." 

1  Many  wounds  of  large  extent  and  deep,  if  tangential  in  nature,  may  be  satis- 
factorily treated  by  nettoyage  and  epluchage  if  they  have  arrived  at  or  passed 
the  period  of  infection  when  first  seen.  If  suppuration  is  already  established 
and  the  original  missile  has  already  procured  debridement  of  the  wound,  excision 
usually  is   unnecessary. 


DEBRIDEMENT  201 

Debridement. — This  term  actually  means  the  relief  of  tension  by 
incision — the  unhridling  of  the  wound.  The  method  has  been  used 
in  surgery  for  generations  for  infected  wounds,  but  as  applied  to  war 
wounds  was  developed  into  a  definite  technique  by  the  teachings  of 
Lemaitre  (1915).  It  is  to  be  applied  to  all  war  wounds  which  show, 
or  which  may  conceivably  develop  subsequently,  infection.  It  is 
especially  necessary  therefore,  in  shell  wounds,  less  so  in  those  by 
bullets;  but  even  in  the  latter,  if  the  tissues  are  at  all  tense  or  pain- 
ful on  gentle  palpation,  and  in  almost  every  case  where  the  bullet 
has  lodged,  debridement  should  be  done.  The  wounds  of  entrance 
and  exit  are  widely  opened  by  incisions,  when  possible  in  the  longi- 
tudinal axis  of  the  limb,  or  parallel  to  the  main  muscular  masses; 
these  debridements  are  frequently  25  to  30  cm.  (10  to  15  inches)  in 
length,  the  usual  error  being  to  make  them  too  small.  The  wound 
area  being  thus  slit  open  and  freely  exposed  to  view,  the  next  step  is 
excision:  first  the  devitalized  skin  immediately  surrounding  the  wounds 
is  cut  away  (no  more  than  is  absolutely  devitalized  should  be  sacri- 
ficed) ;  and  then  the  entire  mass  of  contused  and  lacerated  subcutan- 
eous tissues  and  muscle  is  cut  bodily  away  with  scissors.  Accurate 
anatomical  knowledge  is  requisite  to  avoid  damage  to  important 
bloodvessels  and  nerves.  All  the  devitalized  and  hemorrhagically 
infiltrated  muscle  must  be  excised;  though  it  may  not  be  actually 
invaded  by  bacteria  at  the  time  of  operation  (and  probably  is  not 
until  eight  to  twelve  hours  have  elapsed  since  injury),  yet  if  left  it 
is  certain  to  become  infected.  The  surgeon  should  proceed  methodic- 
ally, excising  piecemeal  these  tissues  until  he  reaches  muscle  which 
when  cut  reacts  promptly  by  contraction.  Usually  in  the  course  of 
the  debridement  and  excision  he  comes  upon  the  shell  fragments  or 
other  foreign  bodies  (clothing,  mud,  wood,  leaves  of  trees,  etc.),  and 
at  once  does  extraction,  which  is  the  third  stage  of  the  operation.  In 
exceptional  cases  the  missile  enters  without  causing  much  laceration, 
and  its  tract  has  to  be  followed  by  dissection,  layer  by  layer,  until  the 
missile  is  found.  When  the  tract  no  longer  can  be  followed  by  the 
eye,  it  is  justifiable  to  insert  the  finger  for  palpation.  Usually  if  the 
missile  is  less  than  0.5  cm.  in  diameter  it  is  useless  to  make  prolonged 
search  for  it,  the  missile  itself  being  comparatively  harmless  after 
removal  of  all  tissues  liable  to  infection.  But  in  every  case  clothing 
or  other  foreign  bodies  should  be  removed.  Frequently  the  missile 
can  be  extracted  more  easily  by  a  counterincision  than  through  the 
wound  of  entrance.1  Finally  hemostasis  must  be  secured,  and  all 
complications  (fractures,  severed  bloodvessels,  tendons  and  nerves) 
must  be  treated  as  will  be  presently  described. 

1  When  difficulty  is  experienced  in  finding  a  missile  which  requires  removal, 
extraction  usually  may  be  accomplished  under  the  fluoroscopic  screen;  or  if  an 
electro-vibrator  is  at  hand,  this  may  indicate  the  location  of  a  steel  fragment  by 
causing  it  to  vibrate  in  the  wound,  the  vibration  being  palpable  to  the  finger  and 
sometimes  visible. 


202  GUNSHOT  WOUNDS 

Drainage  is  very  important.  Most  of  the  tedious  healing  of  wounds 
is  due  to  pocketing  of  infection,  and  this  cannot  he  prevented  unless 
there  is  dependent  drainage.  A  counterincision  made  to,-  extraction 
may  be  used  for  drainage;  hut  it'  not  in  a  suitable  situation  for  secur- 
ing dependent  drainage,  another  counterincision  should  be  made 
where  indicated.  It  should  he  amply  large,  and  a  rubber  tube  (1 
to  l.o  em.  in  diameter)  should  then  he  passed  from  one  wound  to  the 
other;  unless  this  tube  rides  easily  through  the  wound,  without  any 
binding  whatever,  the  wound  should  be  more  widely  opened.  The 
entire  wound  surfaces  are  then  swabbed  with  iodin  (3  per  cent.), 
flavin  (1  to  2000),  picric  acid  (2  per  cent.),  or  Menciere's  solution 
(p.  172).  If  nothing  else  is  available  ether  alone  may  be  used,  but 
this,  as  well  as  Menciere's  solution,  is  apt  to  increase  dozing  of  blood. 

Dressing  the  Wound. — If  debridement  has  been  adequately  done,  and 
all  the  devitalized  tissues  have  been  excised,  it  is  thus  sufficient  to 
provide  a  sewer  (rubber  tube)  which  will  carry  off  the  unavoidable 
wound  secretions,  which,  if  dammed  up  in  puddles,  would  encourage 
the  growth  of  bacteria.  When  drainage  is  provided,  it  is  unnecessary 
and  harmful  to  stuff  the  entire  wound  with  gauze.  Sterile  gauze 
and  cotton  in  abundant  quantities  should  be  applied  to  the  surfaces 
of  the  wound  area,  and  securely  bandaged  in  place.  Fixation  by  splints 
is  of  great  value  for  transportation  even  in  the  absence  of  a  fracture. 

Primary  and  Delayed  Primary  Suture. — If  debridement  is  properly 
done  within  twelve  or  eighteen  hours  of  injury,  and  the  wounds  are 
completely  sutured  (providing  for  drainage)  at  once,  and  if  the 
patients  are  not  evacuated  but  kept  absolutely  quiet,  about  85  per 
cent,  of  such  wounds  will  heal  without  further  trouble;  the  remainder 
will  require  opening  for  infection.  On  the  other  hand,  if  these 
patients,  after  suture  of  the  wounds,  are  evacuated  at  any  time  within 
a  period  of  ten  days  or  two  weeks,  at  least  90  per  cent,  of  such  wounds 
will  break  down  or  require  to  be  opened  for  infection,  and  only  10 
per  cent,  will  heal  without  further  trouble.  Hence  the  absolute 
rule  in  periods  of  great  activity,  when  immediate  evacuation  after 
operation  is  necessary,  that  no  wounds  shall  be  sutured.  But  when 
these  patients,  after  proper  debridement,  reach  the  Bases  where  they 
may  be  kept  permanently,  delayed  primary  suture  is  very  successful. 
If  all  the  wounds  not  involving  bone  are  sutured  immediately  upon 
arrival  at  the  Base,  approximately  85  per  cent,  of  such  wounds  will 
heal  without  further  difficulty,  and  only  15  per  cent,  of  them  will 
require  reopening  for  infection,  and  this  is  so  regardless  of  the  number 
or  kind  of  bacteria  present  in  the  wounds,  with  the  exception  of  the 
streptococcus:  almost  without  exception  wounds  infected  by  the 
streptococcus  will  require  reopening;  and  if  the  presence  of  the  strep- 
tococcus can  be  ascertained  beforehand  (there  is  not  always  time  or 
personnel  for  the  bacteriological  examination  of  all  wounds  within  a 
few  hours  of  their  arrival  at  the  Base),  it  will  be  useless  to  attempt 
suture. 


GUNSHOT  WOUNDS  OF  SPECIAL  STRUCTURES  AND  REGIONS     203 

Secondary  Suture. — Many  wounds,  which  for  some  reason  have  not 
been  treated  by  primary  or  delayed  primary  suture,  may  be  sterilized 
while  granulating,  and  then  secondary  suture  will  prove  successful.1 
The  best  methods  of  chemical  sterilization  have  already  been  dis- 
cussed in  Chapter  VI  (p.  169).  It  should  never  be  overlooked  that 
they  are  efficient  only  when  the  wounds  are  mechanically  prepared 
in  advance;  this  often  requires  a  secondary  operation  (debridement, 
sequestrotomy) ;  and  as  such  operations  in  the  presence  of  streptococcic 
infection  frequently  cause  further  spread  of  the  infection,  it  can  be 
readily  understood  how  difficult  the  sterilization  of  such  wounds  may 
prove.  The  motto  qiiieta  non  movere  surely  applies  to  such  wounds, 
and  if  they  continue  to  heal,  even  if  slowly,  it  is  best  to  pursue  a 
conservative  course. 


Fig.  140. — Mounted  needle  for  secondary  suture. 

To  perform  secondary  suture,  it  usually  is  sufficient  to  freshen  the 
skin  edges,  undermining  them  if  necessary,  and  to  close  the  wound  not 
too  tightly  by  deep  sutures  (Fig.  140.)  It  always  is  important  not  to 
leave  any  dead  spaces,  and  for  this  purpose  buried  sutures  sometimes 
may  be  necessary;  but  their  use,  as  well  as  that  of  drainage,  should  be 
avoided  when  possible. 

GUNSHOT  WOUNDS  OF  SPECIAL  STRUCTURES  AND  REGIONS. 

Bloodvessels. — For  primary  hemorrhage  the  same  rules  apply  here 
as  in  civil  life  (p.  262):  (a)  Usually  the  bloodvessels  are  more  or  less 
contused  by  shell  fragments,  and  thrombosis  is  sufficient  to  prevent 
free  bleeding,  producing  what  are  called  by  the  French  dry  lesions 
(lesions  seches;  Fiolle,  1916);  hence  it  is  important  to  explore  the 
condition  of  the  main  bloodvessels  if  they  are  in  the  tract  of  the 
missile,  whether  or  not  there  is  any  evidence  of  injury;  if  the  lesion 
passes  undiscovered,  secondary  hemorrhage  is  the  rule.  The  danger 
of  gas  gangrene  in  such  cases  has  already  been  noted  (p.  89).  A 
wound  of  the  main  artery,  complicating  a  gunshot  fracture,  usually 
demands  amputation,  (b)  Military  bullets,  however,  groove  or  cut 
across  large  vessels,  and  hemorrhage  is  profuse,  large  pulsating  hemato- 
mas developing  if  death  does  not  occur  from  external  hemorrhage.  Sec- 
ondary hemorrhage  is  a  frequent  sequel,  especially  in  the  presence  of 

1  A  second  injection  of  500  units  of  antitetanic  serum  always  is  to  be  administered 
when  an  operation  is  done  on  parts  which  have  been  wounded  in  battle. 


204 


GUNSHOT   WOUNDS 


infection;  its  treatment  is  described  at  p.  204.     False  aneurysm  (p. 
265)  <>r  arteriovenous  aneurysms  (p.  267)  are  remote  consequences. 

The  general  mortality  from  wounds  of  large  vessels  is  nearly  25  per 
cent.,  and  oxer  10  per  cent,  of  the  patients  finally  come  to  amputation. 
Nerves,  Tendons.  In  warfare  these  are  riot  deflected  by  the  bullet, 
but  are  cut  through.  Nerves  may  be  seriously  injured  also  by  being 
grazed  by  a  bullet,  causing  what  the  Germans  call  an  "  Frschutterung" 
of  the  nerve,  which  England's  great  lexicographer  might  have  trans- 
lated by  the  term  "tremef  action."  Severed  nerves  and  tendons 
should  be  sutured  at  the  time  of  the  debridement,  and  nerves  espe- 
cially should  be  covered  up  inside  the  muscles,  and  not  left  exposed 
in  the  wound. 


Fig.   141. — Thomas  knee  splint  for  transport  of  fractures  of  the  lower  extremity 
(Keller's  half-ring  modification.) 


Fig.  142. — Same  in  use,  on  stretcher. 


Fig.  143. — Hinged  Thomas  traction  arm  splint  for  transport. 


Bones. —  Transportation  of  fracture  cases  is  much  facilitated  by 
the  use  of  the  transport  splints  adopted  during  the  German  War, 
especially  the  modifications  of  the  Thomas  knee  splint  for  fractures 
of  the  lower  extremity  (Figs.  141  and  142),  and  of  the  Thomas 
humerus  splint  for  those  of  the  upper  extremity  (Fig.  143).  They 
should  be  applied  so  as  to  secure  extension  as  well  as  fixation.  In  the 
trenches  or  First  Aid  Station  extension  may  be  secured  by  an  anklet 
applied  over  the  shoe,  or  a  wristlet  applied  over  much  padding;  but  at 
the  Field  Hospital,  or  earlier  if  possible,  these  must  be  replaced  by  adhe- 
sive extension1  applied  to  the  sides  of  the  leg  and  to  the  flexor  and 

1  This  glue  is  used:  resin,  50;  alcohol,  50;  benzin  (pure),  25;  Venice  turpentine,  5. 
It  does  not  require  heating,  and  may  be  removed  with  alcohol  or  ether. 


BONES 


20" 


extensor  surfaces  of  the  forearm.  Too  long  application  of  the  anklet 
and  wristlet  has  caused  many  sloughs.  Extension  during  transport 
is  secured  only  by  counter-extension  against  the  tuber  ischii  or  the 
axillary  folds,  and  cannot  be  maintained  efficiently  for  more  than  a 
few  hours  without  causing  pain  and  perhaps  producing  sloughs. 
When  apparatus  of  this  kind  is  used  as  a  permanent  splint,  exten- 
sion is  secured  by  tying  the  splints  to  fixed  points,  and  (the  foot 
of  the  bed  being  elevated)  letting  the  weight  of  the  limb  or  body  act 
as  counter-extension,  thus  pulling  the  tuber  ischii  or  the  chest  away 
from  the  splint. 


Fig.  144. — Hodgen  splint  for  femur. 

Gunshot  fractures  usually  are  compound,  but  may  be  incidental 
to  a  non-communicating  wound  of  the  soft  parts.  In  the  latter  case 
it  is  not  necessary  to  expose  the  fracture  at  the  debridement.  Frac- 
tures caused  by  perforating  bullet  wounds  without  serious  damage 
to  the  soft  parts  resemble  simple  fractures;  other  gunshot  fractures 
resemble  the  worst  kind  of  compound  fractures  and  are  treated  accord- 
ingly (p.  347):  during  the  debridement  the  fractured  ends  should  be 
exposed,  curetted  and  swabbed  with  iodin  or  other  antiseptic;  reduc- 
tion is  then  secured,  the  soft  parts  dressed,  and  the  splints  re-applied. 

Removal  of  fragments  (esquillectomy)  should  be  parsimonious: 
only  those  actually  detached  should  be  removed,  and  whenever  pos- 
sible subperiosteal  extraction  should  be  practised.  It  is  true  that 
wide  esquillectomy  may  favor  rapid  healing  of  the  wound,  but  it 
usually  leaves  a  flail-like  limb. 

Fractures  of  the  femur  should  be  drained  by  an  incision  15  to  20 


206 


aixsiior  wor.xDs 


cm.  long,  at  the  posterior  border  of  the  vastus  externus,  just  proximal 
to  the  site  of  fracture.  Fractures  of  the  tibia  should  he  drained  by 
an  incision  posterior  to  the  fibula.  In  only  one  of  the  fractures  I 
have  seen  unhealed  after  many  months,  had  dependent  drainage  been 
provided. 

Fracture  cases  bear  evacuation  better  immediately  after  operation 
or  not  for  eight  or  ten  days. 

Treatment  of  fractures  at  the  Base  is  best  done  in  suspension:  the 
Thomas  splints  may  be  used  for  this  purpose,  rendering  the  wounds 
accessible  without  removal  of  the  splint;  but  neither  the  knee  nor  the 
elbow  should  be  kept  in  full  extension  long  (Figs.  144  and  1  15). 


Fig.  145. — Fracture  of  the  humerus  in  suspension  and  traction. 


Joints. — In  all  joint  wounds  the  soft  parts  are  treated  as  if  no  com- 
plicating joint  lesion  existed,  but  extraction,  by  arthrotomy  when 
indicated,  should  precede  the  operation  on  the  septic  soft  parts. 

1.  Clean  perforating  wounds  of  joints,  as  by  the  modern  military 
bullet,  are  to  be  treated  by  aseptic  occlusion  of  the  orifices  and  immo- 
bilization until  the  soft  parts  have  healed.  Then  active  movement  is 
encouraged. 

2.  Penetrating  wounds  with  slight  fracture  are  to  be  treated  by 
arthrotomy,  extraction  and  primary  suture  at  least  of  the  joint  cap- 
sule; it  is  doubtful  whether  irrigation  of  any  kind  is  of  value,  but 
many   surgeons   employ   it    (saline   solution,   ether,    Dakin    solution, 


JOINTS 


207 


etc.).     The  overlying  soft  parts  are  left  open  and  drained  it*  the  patient 
must  be  evacuated,  but  wounds  of  the  knee  at  least  are  considered 


Fig.  146. — Bullet  lodged  in  knee-joint, 
localized  by  skiagraphy;  compare  Figs. 
147,  148,  149.     Episcopal  Hospital. 


Fig.  147. — Lateral  view  (skiagraph) 
of  bullet  lodged  in  knee-joint.  Epis- 
copal Hospital. 


Fig.  14S. — Result  of  arthrotomy  and 
extraction  of  bullet  from  knee-joint  ; 
recent  accident.     Episcopal  Hospital. 


Fig.  149. — Result  of  arthrotomy  and 
extraction  of  bullet  from  knee-joint.  Same 
patient  as  Figs.  146,  147,  and  148.  ■  Epis- 
copal Hospital. 


intransportable.  In  many  cases  extraction  may  be  done  by  enlarg- 
ing the  wound  of  entrance;  in  the  knee,  however,  longitudinal  section 
of  the  patella  (Fig.  473)  gives  better  exposure  and  the  operation  may  be 


208  GUNSHOT  WOUNDS 

concluded  more  rapidly  and  with  less  damage  to  the  joint.  In  such  cases, 
of  course,  the  arthrotomy  wound  is  completely  closed,  only  the  septic 
wound  of  entrance  being  drained  down  to  the  joint  capsule.  If,  as 
is  often  the  case  in  civil  life,  the  bullet  traverses  the  joint  and  is  lodged 
extra-articularly,  it  is  not  necessary  to  open  the  joint  to  extract  it. 
After  arthrotomy,  most  surgeons  practise  immobilization,  and  for  the 
larger  joints  extension  also  is  maintained.  Some  follow  the  teaching 
and  practice  of  Willems  of  Gand  (1917)  who  makes  the  patient  keep 
up  active  movement  in  the  joint  as  often  and  as  long  as  possible;  he 
claims  that  the  more  the  patient  moves  the  joint  (after  the  first  painful 
efforts)  the  better  it  feels.  If  suppuration  follows  the  primary  opera- 
tion, or  occurs  before  the  patient  is  seen:  (a)  reopen  the  joint,  and 
try  chemical  sterilization;  if  this  does  not  immediately  succeed,  aban- 
don it,  and  (b)  trust  to  active  movements  to  secure  drainage:  this 
is  the  plan  Willems  has  adopted  in  many  cases,  and  he  claims  it  secures 
adequate  drainage,  the  movements  forcing  the  pus  out  from  all  crevices 
of  the  articulation;  I  never  saw  this  method  successful,  and  it  is  clear 
that  it  will  not  always  succeed,  as  even  Willems  himself  acknowledges. 
The  next  step  then  (c)  is  icicle  arthrotomy,  with  chemical  disinfection. 
When  even  this  fails,  one  resorts  to  (d)  excision  of  the  joint,  and 
finally   (c)   to  amputation.1 

3.  Penetrating  or  Perforating  Wounds-  with  Notable  Fracture. — If 
removal  of  detached  or  nearly  detached  fragments  will  leave  the  bone 
ends  in  proper  shape  for  joint  function,  esquillectomy  (p.  205)  is  suffi- 
cient; if  this  procedure  utterly  destroys  the  joint  contour,  a  formal 
excision  (p.  510)  is  preferable.  After  excision  of  a  joint  in  military 
surgery,  the  wound  should  be  left  open,  and  chemical  disinfection 
employed.     Amputation  is  most  often  requisite  for  wounds  of  the  knee. 

Head. — In  civil  life  these  injuries  frequently  are  the  result  of  sui- 
cidal attempts,  the  wound  of  entrance  being  in  the  temple,  forehead, 
or  within  the  mouth.  Even  if  the  brain  is  injured  there  may  be  no 
localizing  symptoms  (p.  628).  The  only  indications  for  operative 
treatment  are  (1)  to  disinfect  the  wound  of  entrance;  (2)  to  arrest 
hemorrhage ;  (3)  to  repair  damage  to  the  cranium ;  and  (4)  to  remove  a 
lodged  missile  if  it  is  producing  symptoms.  If  the  wound  of  entrance 
is  small,  not  liable  to  cause  further  trouble  from  infection;  if  the 
fracture  of  the  skull  is  a  mere  puncture,  without  comminution  or 
Assuring;  if  there  are  no  symptoms  of  internal  hemorrhage  or  com- 
pression of  the  brain;  and  if  the  patient  does  not  grow  progressively 
Avorse,  no  operation  should  be  done.  If  the  wound  of  entrance  is 
lacerated,  contused,  filthy,  and  splintering  of  the  skull  is  evident, 
operation  should  be  undertaken  as  in  any  case  of  fracture  of  the 
skull  whether  there  are  cerebral  symptoms  or  not. 

In  warfare  most  wounds  of  the  head  resemble  the  type  just  described; 
but  in  every  case,  no  matter  how  insignificant  the  scalp  wound  appears, 

1  The  average  mortality  of  infected  gunshot  wounds  of  the  knee-joint  is  about  2") 
per  cent.  By  early  arthrotomy  as  indicated  above  it  has  been  reduced  to  less  than 
1  per  cent.,  but  recovery  of  satisfactory  function  is  exceptional. 


THORAX  209 

the  cranium  should  be  exposed.  Local  anesthesia  should  be  used  if 
possible.  The  scalp  wound  should  be  excised,  dirty  or  depressed  bone 
removed,  and  the  dura,  unless  normal,  should  be  opened.  A  hernia 
cerebri  (p.  635),  which  often  presents  in  the  scalp  wound,  should  be 
gently  cleansed;  and  if  the  operation  is  done  under  local  anesthesia 
the  patient  may  be  directed  to  cough,  or  to  strain,  as  this  may  force 
out  of  the  tract  in  the  brain  pulpefied  cerebral  tissue,  and  fragments 
of  bone  or  shell.  This  is  preferable  to  introducing  a  catheter  and 
attempting  evacuation  by  suction,  as  advised  by  Gushing  (1918). 
Unless  fluoroscopy  shows  foreign  bodies  are  very  accessible  no  attempt 
should  be  made  to  extract  them  unless  they  are  causing  symptoms. 
It  is  best  not  to  attempt  reduction  of  the  hernia  cerebri  by  means  of 
lumbar  puncture,  as  this  is  apt  to  rupture  limiting  adhesions  and  to 
be  followed  by  meningitis;  but  merely  to  suture  the  scalp  over  the 
protruding  brain,  disregarding  the  dura.  In  all  cases  it  is  important 
to  close  the  wound  completely,  and  to  do  so  may  necessitate  a  rather 
elaborate  plastic  operation  on  the  scalp;  but  the  results  fully  justify 
such  an  operation.     These  patients  are  intrans  portable. 

Secondary  operation  may  be  required  for  removal  of  a  lodged  missile 
which  is  causing  symptoms.  Most  patients  with  lodged  missiles  die 
suddenly  when  apparently  convalescent,  or  after  developing  a  brain 
abscess  or  meningitis.  Removal  should  be  attempted  by  the  nearest 
approach,  sometimes  along  the  original  tract,  but  often  by  a  counter- 
opening. 

Spine. — The  mortality  from  gunshot  wounds  of  the  spine  in  war  is 
about  66  per  cent.  Nearly  every  case  is  complicated  by  cord  lesion, 
which  may  be  direct,  or  merely  an  "Erschiitterung"  without  rupture 
of  the  dura,  and  even  in  these  cases  a  complete  transverse  lesion  may 
result.  In  civil  life  the  slowly  moving  bullet  usually  is  arrested  by 
the  spine,  and  fracture  without  injury  of  the  cord  is  the  rule.  In 
military  practice  early  operation  is  indicated  only  for  proper  treat- 
ment of  the  soft  parts,  and  extraction  of  easily  accessible  missiles. 
The  modern  teaching  is  that  no  catheter  should  be  passed  for  reten- 
tion of  urine  (for  fear  of  infection),  but  that  the  distended  bladder 
should  be  emptied  by  gentle  pressure  above  the  pubes,  repeating  this 
maneuver  until  the  sphincter  gives  away  and  retention  is  relieved. 
The  question  is  not  settled,  however  (see  p.  645).  These  patients 
should  be  evacuated  immediately  to  the  Base,  where  they  may  be 
hospitalized  indefinitely. 

Thorax. — Gunshot  wounds  of  the  thorax  rarely  are  serious  unless 
they  penetrate  and  wound  the  viscera,  but  shell  fragments  may  cause 
very  severe  damage  to  the  chest  wall,  fracturing  ribs  or  scapula, 
opening  the  pleura  widely  (the  so-called  sucking  wounds),  and  produc- 
ing death  from  shock  without  any  damage  to  the  viscera.  On  the 
other  hand,  bullet  wounds  may  result  in  instant  or  rapid  death  from 
injury  to  the  heart  or  great  bloodvessels,  with  insignificant  injury 
to  the  chest  wall.  In  warfare  a  bullet  seldom  lodges;  in  civil  life  it 
nearly  invariably  is  arrested,  frequently  being  found  beneath  the  skin 
14 


210  GUNSHOT  WOUNDS 

on  the  opposite  side  of  the  body.  It  is  important  to  look  for  it  care- 
fully beneath  the  skin,  if  there  is  no  wound  of  exit,  so  as  to  determine 
its  course  through  the  thorax.  A  bullet  may  seem  to  traverse  the 
thorax,  and  yet  wound  no  viseus;  while  a  wound  which  does  not  pene- 
trate far  may  cause  alarming  hemorrhage  from  the  internal  mammary 
or  an  intercostal  artery. 

Symptoms.  In  sucking  wounds  there  is  great  dyspnea,  and  shock 
often  is  pronounced.  In  penetrating  or  perforating  bullet  wounds,  with 
punctiform  orifices,  and  if  the  course  of  the  bullet  is  above  the  level  of 
the  anterior  end  of  the  fifth  rib,  and  there  arc  no  signs  of  serious  internal 
hemorrhage  (p.  259),  it  is  probable  that  the  upper  part  of  the  lung 
has  been  wounded  at  its  periphery.  If  the  bullet  is  of  small  caliber, 
pulmonary  tissue  expands  and  occludes  the  wounds  of  entrance  and 
exit  in  the  lung,  and  little  bleeding  occurs  into  the  pleural  cavity. 
A  larger  bullet,  and  most  shell  fragments,  will  produce  more  of  a 
lacerated  wound,  and  the  signs  of  hemothorax  (sometimes  pneumo- 
hemothorax)  quickly  develop.  Subcutaneous  emphysema  (p.  77(5) 
is  not  infrequent.  In  nearly  every  case  the  physical  signs  of  a  more 
or  less  diffuse  bronchitis  appear;  bloody  mucus  is  expectorated; 
moderate  fever  occurs;  and  the  patient  passes  through  an  atypical 
attack  of  pneumonia.  Dyspnea  rarely  is  severe  unless  from  internal 
hemorrhage  or  from  pneumothorax.  If  the  bullet  passes  below  the 
level  of  the  fifth  rib,  it  may  involve  the  diaphragm,  or  pierce  this,  and 
entering  the  abdomen  wound  the  subdiaphragmatic  viscera. 

Treatment. — 1 .  Wounds  by  Shell  Fragments. — Sucking  wounds  should 
be  tamponed  with  gauze  as  soon  as  the  wounded  man  is  found,  and 
morphin  administered.  At  the  Evacuation  Hospital  the  soft  parts 
of  the  chest  wall,  and  fractures  of  ribs  or  scapula,  are  to  be  treated  as 
if  no  visceral  lesion  existed  (debridement,  excision,  extraction),  and 
the  pleural  cavity  is  to  be  closed  by  suture  of  the  muscles  across  the 
opening  with  only  superficial  drainage.  Only  if  a  shell  fragment  is 
easily  accessible  should  attempts  be  made  to  remove  it  from  the  lung; 
then  the  lung  should  be  grasped  in  the  fingers  or  volsellum  forceps, 
the  missile  located  by  palpation,  an  incision  made  in  the  visceral 
pleura  over  it  where  most  accessible,  and  extraction  done.  If  the 
pleural  incision  is  small,  no  suture  is  needed.  The  chest  is  closed 
without  drainage.  The  operation  has  been  systematized  by  P.  Duval 
(1915).  In  the  majority  of  cases  the  missile  is  small  and  provocative 
of  no  symptoms  if  allowed  to  remain,  and  pulmonary  complications 
are  unusual.  If  extraction  is  subsequently  required,  it  is  better  to 
do  open  thoracotomy,  according  to  Duval's  plan;  though  Petit  de  la 
Villeon  (1916)  has  practised  in  a  large  number  of  cases  with  great 
success,  under  fluoroscopy,  extraction  by  a  long  forceps  introduced 
through  a  buttonhole  intercostal  incision.  Most  of  his  operations 
were  done  weeks  or  months  after  injury. 

2.  Bullet  Wounds. — Wounds  above  the  level  of  the  fifth  rib  seldom 
require  operation;  the  orifices  should  be  cleansed  and  occluded  with 
sterile  dressings,  and  the  affected  side  of  the  chest  strapped,  as  for 


ABDOMEN  .      211 

fractured  ribs  (p.  359).  Dyspnea  is  to  be  controlled  by  opiates.  In 
any  case  where  the  abdominal  contents  may  have  been  wounded 
exploratory  laparotomy  is  indicated.  When  dyspnea  is  extreme,  and 
the  pleura  is  filled  with  fluid,  it  is  better  to  evacuate  this  through  an 
incision  in  the  ninth  or  tenth  intercostal  space,  posteriorly.  This 
should  also  be  done  when  an  infected  hemothorax  is  encountered.  If 
there  is  persistent  internal  hemorrhage,  open  thoracotomy  (p.  785) 
is  indicated.     It  is  best  not  to  drain  the  thorax,  unless  already  infected. 

Abdomen. — Gunshot  wounds  of  the  abdomen  may  involve  only  the 
parietes,  and  in  a  patient  with  a  very  fat  or  pendulous  abdomen  the 
bullet  may  enter  in  front  and  lodge  in  the  groin  or  flank  without 
penetrating  the  peritoneum.  Every  case,  however,  should  be  sub- 
jected to  exploratory  operation,  whether  in  military  or  civil  practice, 
provided  ample  facilities  exist;  and  patients  should  not  be  moved  for 
two  weeks  after  operation.  If  abstention  from  operation  is  uniformly 
practised  in  war,  the  mortality  is  considerably  higher  than  when  imme- 
diate operation  is  done  in  all  cases.  Bullet  wounds  are  less  dangerous 
than  those  from  shell  fragments,  the  respective  mortality,  according  to 
Chalier  and  Glenard  (1917),  being  42  and  68  per  cent.  The  surgeon 
should  abstain  from  operation  only  when  the  patient  is  first  seen  from 
twenty-four  to  forty-eight  hours  after  injury,  and  if  there  are  no 
abdominal  symptoms.  If  no  operation  can  be  done,  for  any  cause, 
the  non-operative  treatment  for  peritonitis  (p.  862)  should  be  adopted. 
Such  patients  sometimes  live  to  develop  a  localized  abscess,  a  fecal 
fistula,  or  even  intestinal  obstruction,  which  may  be  treated  success- 
fully by  a  late  operation. 

In  civil  life,  nearly  half  the  patients  recover  if  operation  is  done 
within  tAvelve  hours;  after  that  time  only  one  out  of  four  recovers. 
Though  the  mortality  in  civil  practice,  even  after  prompt  operation, 
is  thus  seen  to  be  nearly  as  high  as  in  military  surgery,  it  must  be 
remembered  many  patients  who  die  on  the  field  or  in  advanced  posts 
are  not  included  in  the  military  statistics. 

The  diagnosis  and  operative  treatment  of  penetrating  wounds  of  the 
abdomen  are  discussed  in  Chapter  XXII. 


CHAPTER  VIII 


AMPUTATIONS. 


Amputation,  derived  from  the  Latin  word  meaning  to  lop  off, 
to  prime,  etc.,  is  by  surgeons  usually  confined  in  its  application  to 
the  removal  of  a  limb,  or  part  of  a  limb.  If  the  member  is  removed 
at  a  joint,  the  operation  may  be  termed  an  exartieidation,  or  a  dis- 
articulation;  if  through  the  bones,  the  operation  is  an  amputation  in 
continuity. 

Conditions  Requiring  Amputation.  —  Among  the  most  frequent 
and  important  are:  (1)  Avulsion,  or  traumatic  amputation,  of  a  limb; 
here  there  is  no  alternative  but  to  trim  up  the  stump  that  is  left  so 
as  to  hasten  healing  and  secure  good  functional 
result.  (2)  Compound  fractures  and  luxations, 
which  sometimes  leave  the  limb  attached  only 
by  a  few  shreds  of  muscle  or  a  strip  of  skin. 
(3)  Lacerated  and  contused  wounds,  even  without 
fracture,  sometimes  exhibit  such  extensive 
destruction  of  the  soft  parts  as  to  demand 
the  removal  of  the  limb.  In  general,  if  the 
limb  is  sure  to  be  useless  if  retained,  or  if  it  is 
sure  to  become  gangrenous,  it  should  be  re- 
moved. (4)  Injury  of  the  main  artery  of  a  limb, 
when  it  occurs  at  a  site  which  habitually  results 
in  gangrene,  usually  is  a  cause  for  amputation 
( p .  6 1 ) .  ( 5 )  Gan  gren  e ,  when  con st itut i n g  m ore 
than  a  superficial  slough,  usually  is  a  cause  for 
amputation.  The  special  varieties  of  gangrene, 
and  the  proper  time  for  amputation,  as  wrell  as 
the  level  where  this  should  be  done,  have  been 
considered  in  Chapter  II.  Gas  gangrene  is 
discussed  at  p.  88.  (6)  Septic  wounds,  espe- 
cially if  complicated  by  lesions  of  bone  or  joints, 
come  to  amputation  as  a  life-saving  measure. 
(7)  Diseases  of  bones  and  joints ;  these  are  much 
less  often  a  cause  for  amputation  now  than 
formerly.  (8)  Malignant  tumors  frequently  necessitate  amputation. 
(9)  Deformity,  including  also  certain  non-malignant  tumors,  may  very 
occasionally  be  a  cause  for  amputation. 

Instruments. — These  include  a  tourniquet  (Fig.  150),  or  an  Esmarclis 

band  (Fig.  151)  for  controlling  the  circulation;  amputating  knives  for 

dividing  the  soft  parts;  periosteotome,  or  raspatory;  retractors  to  guard 

the  soft  parts  from  the  saw;  bone  forceps,  to  steady  the  bone  as  it  is 

(212) 


Fig.    150. — Screw     tourni- 
quet applied  to  thigh. 


INSTRUMENTS 


213 


sawed,  in  cases  of  avulsion  or  traumatic  amputation,  and~J>one  nippers 
to  trim  rough  edges  off  the  bone  after  it  has  been  sawed;  hemostatic 


Fig.  151. — Esmarch  band,  showing  proper  method  of  its  application. 


Fig.  152. — Amputating  instruments.  1.  Large  amputating  knife.  2.  Catlin  (double- 
edged  knife).  3.  Small  amputating  knife.  4.  Metacarpal  knife.  5.  Periosteotome  or 
raspatory.     6.  Phalangeal  saw.     7.   Metacarpal  saw.     8.  Large  amputating  saw. 

forcejjs,    as   well  as  ligatures,   sutures,  needles,   and   scissors.     These 
instruments  are  illustrated  in  Figs.  152  and  153. 


21  I 


AMPUTATIONS 


Tourniquet. — The  screw  tourniquet  (Petit,  L690)  is  seldom  employed 
now,  Esmarch's  elastic  hand  (1873)  having  largely  superseded  it. 
Before  applying  either,  especially  in  shocked  or  anemic  patients, 
the  limb  should  be  elevated  for  a  few  moments,  so  as  to  empty  it  of 
venous  blood.  The  tourniquet,  when  used,  should  be  placed  upon 
the  limb  so  that  the  screw  is  either  directly  over  the  main  vessels,  or 
at  a  point  diametrically  opposite  to  them,  compressing  them  against 
bone;  and  a  compress  (as  a  roller  bandage)  should  be  placed  between 
the  tourniquet  and  the  main  vessels,  so  that  greater  pressure  will  be 
brought  to  bear  on  them  than  on  the  surrounding  soft  parts.  After 
fixing  the  tourniquet  in  place  by  buckling  the  strap  tight,  the  plates 


Fig.  153. — Amputating  instruments.  1.  Hemostatic  foceps.  2.  Curved  hemostatic 
forceps.  3.  Fergusson's  "lion-jawed"  bone-holding  forceps.  4.  Liston's  bone-cutting 
forceps  ("nippers").    5.   Farabeuf's  bone-holding  forceps. 


are  separated  by  turning  the  screw,  thus  drawing  the  encircling  strap 
tighter  and  forcing  the  compress  against  the  vessels  until  distal 
pulsation  is  arrested.  Esmarch's  elastic  band  is  wrapped  around 
the  limb  three  or  four  times,  each  turn  being  directly  superposed 
upon,  and  being  drawn  a  little  tighter  than  the  previous  one,  until 
the  circulation  is  arrested.  If  not  drawn  tight  enough,  it  will  increase 
venous  bleeding;  if  drawn  too  tight,  it  may  cause  local  sloughing 
and  subsequent  gangrene  of  the  entire  limb;  or  paralysis  from  pressure 
on  the  nerves,  especially  above  the  elbow,  when  the  ulnar  or  musculo- 
spiral  nerve  may  be  injured.  In  emergencies  the  "Spanish  windlass" 
(Morel,  1674)  may  be  used  (Fig.  154),  or  even  Momburg's  method  of 
hemostasis  (p.  235). 


OPERATIVE  PROCEDURES 


215 


Amputating  Knives. — The  length  should  be  about  one  and  a  half 
times  the  diameter  of  the  limb  to  be  removed,  and  the  blade  should 
be  from  1  to  2  cm.  wide;  one  of  20  or  25  cm.  is  suitable  for  the  thigh  or 
hip;  one  of  15  cm.  for  the  forearm,  arm  or  leg;  while  for  the  hand  or 
foot  a  metacarpal  amputating  knife  (Fig.  152,  4),  with  a  blade  7.5  cm. 
long  and  0.5  cm.  wide,  is  preferable.  Double  edged  catlins  occasionally 
are  used  for  the  forearm  or  leg,  to  aid  in  clearing  the  interosseous 
space.  The  raspatory  is  used  to  separate  the  periosteum  before  apply- 
ing the  saw,  thus  avoiding  ragged  division  of  the  periosteum  by  the 
saw.  The  retractor  is  made  of  muslin,  being  two-tailed  for  the  humerus 
and  femur  ( Fig.  155),  and  three-tailed  for  the  forearm  and  leg  (Fig.  150 1 . 


gSfe 


Fig.  155.- 


-Two-tailcd  muslin  retractor,  for  amputations 
of  the  arm  and  thigh. 


Fig.  154. — The  "Spanish 
windlass." 


Fig.  156.- 


-Three-tailed  retractor  applied  for  an 
amputation  of  the  leg. 


The  amputating  saw  is  about  25  cm.  long  by  5  cm.  wide;  strong- 
backed,  and  with  widely  set  teeth.  A  smaller  saw  is  used  for  the 
hand  and  foot.  Bone-nippers  are  sometimes  used  for  amputating 
phalanges,  though  they  are  apt  to  splinter  the  bone;  and  if  larger 
bones  are  properly  sawed,  there  should  be  no  rough  edges  to  trim  off. 
Ligatures  are  of  absorbable  material,  as  are  the  buried  sutures;  skin 
sutures  usually  are  of  silkworm  gut. 

Operative  Procedures. — A  patient  who  is  to  have  a  limb  removed 
usually  is  in  a  weakened  and  precarious  state,  either  from  shock 
and  hemorrhage  following  an  accident,  or  from  the  cachexia  of  chronic 
disease.     Hence  it  is  the  surgeon's  duty   to  take   special   pains  to 


216  AMPUTATIONS 

prevent  loss  of  bodily  heat,  and  needless  waste  of  time.  In  cases 
of  accident  it  frequently  is  necessary  to  prepare  the  limb  for  ampu- 
tation after  the  patient  is  on  the  table,  while  the  anesthetic  is  being 
administered.  The  surgeon  and  his  first  assistant  should  be  ready 
to  commence  the  operation  the  instant  that  the  patient  is  under  the 
anesthetic,  and  the  preparation  of  the  limb  should  be  complete  at 
the  same  time.  While  one  assistant  raises  the  limb,  the  surgeon 
applies  the  tourniquet,  or  if  he  entrusts  this  important  duty  to  an 
assistant,  he  should  make  sure  before  commencing  his  operation  that 
the  circulation  is  properly  arrested  and  that  there  is  no  danger  of 
the  tourniquet  slipping.  One  assistant  should  give  his  entire  attention 
to  the  tourniquet  throughout  the  operation.  Another  assistant  holds 
the  limb  in  a  convenient  position,  clear  of  the  table,  and  the  surgeon, 
standing  with  his  left  hand  to  the  patient's  trunk,1  so  as  to  be  able  to 
control  the  main  artery  should  the  tourniquet  slip,  divides  the  soft 
parts  and  the  periosteum,  as  will  be  presently  directed;  and,  while  the 
soft  parts  are  drawn  out  of  the  way  and  protected  by  the  retractor, 
saws  the  bone,  his  assistant  guarding  against  binding  of  the  saw  by  the 
manner  in  which  he  holds  the  limb.  As  soon  as  the  limb  has  been 
removed,  the  surgeon  applies  to  the  face  of  the  stump  a  folded  towel, 
lightly  wrung  out  of  very  hot  antiseptic  solution;  this  checks  the  slight 
venous  ooze,  and  as  it  is  gradually  withdrawn,  the  surgeon  catches  with 
hemostats  all  the  vessels  large  enough  to  have  names,  and  ties  them  all. 
The  main  artery  and  vein  of  the  arm  or  thigh  should  be  tied  separately; 
smaller  arteries  may  be  included  in  one  ligature  with  their  accom- 
panying veins.  Then  another  hot  antiseptic  towel  is  applied  to  the 
face  of  the  stump,  and,  the  limb  being  held  as  nearly  vertical  as 
possible,  the  tourniquet  is  completely  removed.  If  it  is  only  partially 
loosened,  venous  bleeding  is  increased.  If  the  surgeon  has  done  the 
operation  with  due  care,  there  should  now  remain  only  a  few  oozing 
points  in  the  muscular  masses,  which  can  be  controlled  by  sutures. 
If  the  soft  parts  have  been  cut  dexterously,  with  long  sweeps  of  a 
sharp  knife,  the  tendons  and  nerves  are  cut  cleanly  across,  will  not 
be  redundant,  and  will  not  require  to  be  retrenched.  Hemorrhage 
from  the  medulla,  which  is  unusual,  should  be  controlled  by  plugging 
with  muscle  tissue,  by  packing  with  Horsley's  wax,  or  in  emergency 
with  gauze.  Finally,  the  stump  is  closed,  with  a  few  buried  mattress 
sutures  of  chromic  catgut  approximating  the  ends  of  opposing  sets 
of  muscles.  A  rubber  drainage  tube  is  placed  across  the  face  of  the 
stump,  just  beneath  the  skin,  and  the  skin  is  closed  with  interrupted 
sutures  of  silkworm  gut. 

Dressing  the  Stump. — Moderate  pressure,  rest,  and  mechanical 
protection  are  necessary.  Abundant  sterile  gauze  dressings  are 
applied,  and  in  a  certain  definite  manner.  Ruffled  gauze  is  placed 
around  each  end  of  the  tube,  one  end  of  which  may  be  left  long  and 
brought  out  of  the  deep  into  the  superficial  dressings,  as  described 

1  In  amputating  the  left  lower  extremity  he  stands  between  the  patient's  legs. 


GUILLOTINE   AMPUTATION 


21* 


at  p.  166.  The  special  amputation  dressing  is  cut  as  shown  in  Fig. 
157;  the  transverse  portion  is  placed  beneath  the  limb,  and  folded 
around  it,  the  longitudinal  portion  being  then  folded  up  over  the  end 
of  the  stump.  Over  the  gauze  dressings  an  abundant  amount  of 
sterile  absorbent  cotton  is  arranged,  burying 
the  end  of  the  tube,  and  the  whole  is  band- 
aged snugly  on  to  the  stump.  It  is  surprising 
how  much  diminution  in  size  an  apparently 
bulky  dressing  undergoes  when  it  is  properly 
bandged.  Next  the  limb  is  bandaged  firmly  to 
a  splint,  which  projects  some  inches  beyond 
the  end  of  the  stump.  It  is  never  safe  to  as- 
sume that  cases  of  amputation,  especially  recent 
accidents,  will  be  free  from  traumatic  delirium, 
and  the  proper  time  to  protect  the  limb  from 
injury  is  before  the  delirium  develops.  The 
stump  should  be  kept  as  nearly  vertical  as  pos- 
sible for  twelve  hours.  Usually  the  drainage 
tube  may  be  removed  at  the  end  of  twenty- 
four  to  thirty-six  hours ;  and  the   stump  need 

not  be  dressed,  if  all  goes  well,  until  time  to  remove  the  skin  sutures. 
Methods  of  Operating. — Every  method  of  amputating  may  be 
considered  a  variety  either  of  the  circular  or  the  flap  method.  The 
circular  method  is  to  be  preferred  whenever  a  choice  is  possible; 
it  is  suited  for  all  limbs  where  the  bones  are  approximately  in  the 
center  of  the  soft  parts  (lower  forearm,  arm,  thigh),  provided  the 
limb  is  not  conical  in  shape.  It  is  not  desirable  in  amputations  at 
joints,  nor  in  the  leg,  where  a  weight-bearing  stump  is  sought,  since 
the  cicatrix  always  falls  across  the  face  of  the  stump. 


Fig.  157.— Method  of 
cutting  and  applying 
gauze  for  dressing  an  am- 
putation stump. 


Fig.  158. — Traction  on  guillotine  stump. 


Guillotine   Amputation   {Amputation  en    Saucisse). — This  primitive 
method  has  been  revived  during  the  German  War,  as  a  preventative 


218  AMPUTATIONS 

of  septic  complications  (Pauchet,  1914) :  all  the  tissues  are  divided 
at  the  same  level;  the  skin  and  muscles  retract,  leaving  an  exposed 
conical  stump,  open  to  antiseptic  treatment.  When  granulations 
commence,  traction  should  he  applied  (Fig.  158)  and  in  a  few  cases 
healing  will  occur  without  further  operation.  In  most  cases,  how- 
ever, it  is  necessary  eventually  to  trim  off  the  bone  and  do  secondary 


FlG.  159. — Guillotine  amputation  of  the  thigh,  after  extension  had  been  applied  for 
weeks.  Ready  for  secondary  suture.  Re-amputation  not  necessary.  Walter  Reed 
General  Hospital. 

suture  (Fig.  159.)  This  is  the  form  of  amputation  to  be  preferred  in 
exceedingly  septic  cases,  as  an  emergency  method;  it  exposes  the  least 
possible  area  to  infection  and  leaves  the  least  possible  surface  to  heal. 
Esmarch,  over  thirty  years  ago,  employed  what  he  called  the  Einschnitt 
Method,  which  was  in  all  respects  similar  to  the  guillotine  method, 
except  that  Esmarch  applied  one  or  two  sutures  to  the  center  of  the 
skin  incision,  letting  the  sides  gape  for  drainage. 


Fig.  160. — Circular  amputation  of  the  forearm,  showing  method  of  holding  the 
knife  as  the  first  incision  is  started. 

Circular  Amputation. — In  this  method  all  the  tissues  of  the  limb 
are  severed  by  circular  incisions,  the  skin  at  the  lowest,  the  muscles 
at  an  intermediate,  and  the  bone  at  the  highest  point  ("triple  in- 
cision" method  of  Hey  and  Bell,  about  1800).     The  surgeon  passes 


CIRCULAR  AMPUTATION 


210 


the  knife  under,  around,  and  over  the  limb,  so  that  its  point  is  down, 
and  its  back  toward  his  own  face  (Fig.  160);  then,  pressing  the  heel  of 
the  knife  well  into  the  flesh,  with  one  long  steady  sweep  he  divides 
the  skin  and  subcutaneous  tissues  down  to  the  deep  fascia,  the  blade 
ending  with  its  point  exactly  in  the  place  where  its  heel  began  the 
incision.  The  surgeon  now  dissects  the  skin  up,  with  the  same 
knife,  for  a  distance  equal  to  half  the  diameter  of  the  limb,  taking 
care  always  to  direct  his  blade  toward  the  deeper  structures  so  as 
to  leave  uninjured  the  cutaneous  vessels,  and  thus  ensure  the  vitality 
of  the  skin.  Then  the  muscles  are  similarly  divided  down  to  the 
bone,  with  the  same  knife,  by  a  circular  cut  at  the  point  of  reflection 


Fig.  161. — Skiagraph  of  stump  resulting  from  amputation  of  leg  by  modified 
Sedillot  method.     Episcopal  Hospital. 


of  the  skin.  The  muscles  are  not  separated  from  the  periosteum 
further  than  is  necessary,  but  this  is  cut  through  by  a  sharp  knife 
and  scraped  upward  for  2  or  3  cm.  In  the  forearm  and  leg  the 
interosseous  space  must  be  cleared  also;  in  doing  this  the  surgeon 
should  studiously  avoid  turning  the  edge  of  his  knife  upward,  toward 
the  patient's  trunk,  for  fear  of  nicking  bloodvessels  higher  than 
they  can  be  conveniently  tied.  When  the  bone  has  been  cleared, 
the  muslin  retractor  is  applied,  each  end  overlapping  the  other,  and 
all  being  drawn  upward  by  an  assistant.  The  bone  is  then  sawed, 
at  right  angles  to  its  long  axis,  without  injury  to  the  periosteum. 
In  the  forearm  both  bones  are  sawed  at  the  same  level,  and  simulta- 


220  AMPUTATIONS 

neously;  in  the  leg,  the  fibula  is  sawed  first  and  at  least  2  cm.  higher 
than  the  tibia  (Fig.  l(il).  After  suturing  the  muscles,  the  skin 
incision  may  be  closed  transversely  or  anteroposterior^'  as  seems  best. 

Sometimes  in  a  conical  limb  there  is  difficulty  in  dissecting  back 
the  circular  cuff  of  skin,  as  above  described;  then  it  may  be  slit  at 
one  or  two  points.  If  slit  at  only  one  point,  and  the  angles  rounded 
off,  this  constitutes  the  Racket  Method,  named  from  its  resemblance  to 
a  tennis  racket,  and  habitually  employed  in  many  disarticulations. 
The  Oval  or  Elliptical  Method,  a  modification  of  the  racket  method,  is 
employed  in  many  amputations  without  the  formality  of  commencing 
it  as  a  circular  amputation,  by  making  the  first  skin  incision  in  the 
form  of  an  ellipse.  If  the  cuff  of  skin  is  slit  at  two  points,  and  the  angles 
rounded  off,  the  amputation  becomes  one  by  skin  flaps,  commonly 
called  the  Modified  Circular  Method. 

Flap  Amputation. — The  flaps  may  include  the  skin  and  superficial 
muscles,  or  the  entire  muscular  mass  with  the  skin.  The  flaps  may 
be  rectangular  or  curved  in  outline,  and  may  be  cut  from  without 
inward  or  by  transfixion.  They  always  should  be  of  equal  breadth 
at  their  base,  whether  they  are  of  equal  or  unequal  length.  Their 
combined  length  should  equal  one  and  a  half  times  the  diameter  of 
the  limb.  Care  should  be  exercised  to  have  the  main  bloodvessels  in 
one  flap  or  the  other  (usually  in  the  shorter),  and  not  at  a  point  where 
they  may  be  slit  up  as  the  flaps  are  being  formed.  In  amputating 
by  transfixion  the  surgeon  raises  the  tissues  to  be  cut  with  his  left  hand, 
and  entering  the  point  of  the  knife  at  the  side  of  the  limb  nearest 
himself,  pushes  it  across  and  around  the  bone,  and  brings  its  point 
out  diametrically  opposite  its  place  of  entrance.  The  flap  is  then 
formed  by  cutting  first  downward  and  then  rapidly  outward,  with  a 
vigorous  sawing  motion.  The  knife  is  then  reentered  as  before,  pass- 
ing on  the  opposite  side  of  the  bone,  and  the  second  flap  is  cut.  The 
remaining  fibers  are  then  divided  by  a  circular  sweep,  and  the  opera- 
tion terminated  as  already  described.  The  flap  which  contains  the 
principal  bloodvessels  should  be  cut  last.  Usually  it  is  more  conven- 
ient to  form  the  flaps  by  cutting  from  without  inward;  or  the  second 
flap  only  may  be  cut  by  transfixion.  Though  an  amputation  may  be 
performed  more  rapidly  by  transfixion,  this  method  has  lost  in  favor 
since  the  introduction  of  anesthesia;  since  by  cutting  from  without 
inward  the  flaps  may  be  more  accurately  shaped,  and  the  main 
bloodvessels  may  be  severed  transversely,  instead  of  obliquely  as 
frequently  happened  in  cutting  flaps  by  transfixion. 

Multiple  Amputations.— It  is  occasionally  necessary  to  remove 
two  or  more  limbs  at  the  same  time.  Under  such  circumstances  it 
is  best  to  do  the  amputation  of  greatest  magnitude  and  severity 
first;  and  for  the  same  surgeon  to  proceed  immediately  afterward  to 
remove  the  second  and  third  limb,  if  the  patient's  condition  warrants 
the  continuance  of  the  operation.  If  it  does  not,  hemorrhage  from 
the  remaining  limb  or  limbs  must  be  temporarily  controlled,  and 
further  operation  postponed.     For  two  or  more  surgeons  to  operate 


DISEASES  OF  STUMPS 


221 


on  different  limbs  simultaneously  usually  increases  the  shock  to  the 
patient.  Multiple  amputations  for  gangrene  following  frostbite  are 
much  less  serious  than  those  for  traumatic  cases. 

Structure  and  Diseases  of  Stumps. — A  stump  not  only  goes  through 
the  processes  of  inflammatory  reaction,  cicatrization  and  contrac- 
tion; but  there  also  occurs  actual  atrophy 
of  the  muscular  tissues  from  disuse;  the 
bone  becomes  rounded  off  and  atrophies; 
the  nerves  degenerate,  and  usually  become 
bulbous,  but  will  not  be  painful  unless 
caught  in  the  cicatrix.  The  muscles  occa- 
sionally become  unduly  atrophied  and  re- 
tracted, leaving  the  ends  of  the  bone  covered 
only  by  skin,  or  even  causing  the  incision 
to  break  open,  and  producing  a  painful 
ulcer.  Sometimes,  from  continued  growth 
of  bone,  a  conical  stump  is  formed  (Fig.  163). 
This  usually  is  due  to  the  natural  develop- 
ment of  the  bone,  being  seen  oftenest  in 
amputations  of  the  upper  arm  in  children, 
as  the  growth  of  the  humerus  takes  place 
chiefly  at  the  upper  epiphysis.  Sometimes 
a  conical  stump  forms  in  the  leg  in  child- 
hood, the  growth  occurring  from  the  upper 
epiphysis  of  the  tibia;  whereas  in  the  fore- 
arm and  thigh,  the  greater  part  of  the  growth 
comes  from  the  lower  epiphyses.  For 
conical  stumps,  and  for  intractable  ulcers, 
adherent  to  the  bone,  which  cannot  be 
cured  by  palliative  means,  there  is  no  remedy 
short  of  re-amputation,  which,  fortunately,  is 
a  much  less  serious  operation  than  amputa- 
tion. It  sometimes  is  possible  to  resect  the  end  of  the  bone,  without 
doing  a  formal  amputation  again.  In  cases  which  have  been  septic 
it  is  best  to  remove  sequestra  first,  and  not  to  do  secondary  suture 
until  a  later  occasion,  after  all  swelling  has  subsided.  By  a  plastic 
operation  it  may  be  possible  to  secure  closure  without  removal  of 
more  bone.  Stumps  must  have  a  certain  length  to  be  useful  with 
artificial  limbs:  too  short  stumps  are  a  hindrance.  At  least  4  cm.  on 
the  flexor  side  of  the  bent  knee,  enough  of  the  femur  to  project  well 
beyond  the  level  of  the  tuber  ischii,  and  of  the  humerus  to  clear  the 
axillary  folds,  are  required  to  keep  the  stump  from  riding  out  of  the 
socket  of  the  prosthesis. 

A  good  stump  is  one  which  is  painless  and  which,  in  the  lower 
extremity,  can  be  used  to  support  the  weight  of  the  body  through 
an  artificial  limb.  The  bones  should  be  well  covered  with  soft  parts, 
and  these  soft  parts  should  not  be  adherent  to  the  ends  of  the  bone;  if 
there  are  no  such  adhesions  it  makes  no  particular  difference  whether 


Fig.  162. — Double  amputa- 
tion, circular  of  thigh  and  Cho- 
part's  of  foot.  Episcopal  Hos- 
pital. 


9.9.9 


AMPUTATIONS 


the  cutaneous  cicatrix  lies  across  the  end  of  the  stump  or  at  one  side; 
but  there  are  much  less  apt  to  be  adhesions  to  the  bone  if  the  cicatrix 


Fig.  103. — Conical  or  sugar-loaf  stump  from  continued  growth  of  bone  after  ampu- 
tation in  early  youth.  From  a  patient  in  the  Pennsylvania  Hospital  under  the  care 
of  the  late  Prof.  Ashhurst. 


of  skin  as  well  as  of  muscle  lies  to  one  side  of,  rather  than  directly  over, 
the  end  of  the  bone.     Few  stumps  will  bear,  by  direct  pressure  on  their 

ends,  the  entire  weight  of  the  body, 
and  most  artificial  limbs  are  made 
to  obtain  their  chief  support  from 
surrounding  bony  points  (head  of 
the  tibia,  tuberosity  of  the  ischium). 
But  Bier  (1895)  advocated  an  osteo- 
plastic method  of  amputating,  after 
the  Pirogoff  principle,  by  means  of 
which  end-bearing  stumps  may  be 
obtained  (Fig.  164).  Bunge  (1905) 
found  that  by  sawing  the  bone  2  mm. 


Fig.  164.  —  Bier's  osteoplastic 
method  of  amputation.  The  bones 
are  sawed  at  two  levels,  and  a  flap 
of  the  tibia  turned  across  the  ends 
at  the  last  section. 


Fig.  105.— Amputation  of  leg  by  aperiosteal 
method  of  Bunge. 


MORTALITY  AFTER  AMPUTATION 


223 


below  the  level  at  which  the  periosteum  is  divided,  and  scraping  out 
the  marrow  cavity  for  the  same  distance,  end-bearing  stumps  may  be 
obtained  without  any  osteoplastic  oper- 
ation. He  makes  his  flaps  of  skin  only 
(Fig.  165).  The  oval  method  is  suitable 
for  such  cases.  I  have  used  this  method 
with  perfect  success  (1911)  (Fig.  166). 

After-treatment  of  Stumps. — It  is  im- 
portant to  prevent  contractures  of 
neighboring  joints,  especially  flexion  of 
the  knee,  flexion  and  adduction  of  the 
hip,  and  loss  of  supination  in  the  fore- 
arm and  of  abduction  at  the  shoulder. 
Active  exercises  for  this  purpose  should 
be  instituted  so  soon  as  the  condition 
of  the  stump  permits,  usually  within 
ten  days  or  two  weeks;  and  so  soon  as 
the  stump  is  healed  it  should  be  fitted 
with  a  temporary  prosthesis  and  active 
use  encouraged.  This  develops  the 
muscles  which  move  the  stump  and 
greatly  hastens  the  return  of  function. 
In  the  lower  extremity  a  bucket  of 
plaster  of  Paris,  moulded  to  the  stump, 
may  be  attached  to  a  peg-leg  for  tem- 
porary use.  The  permanent  prosthesis  may  then  be  fitted  as  soon  as 
the  stump  ceases  to  shrink. 

Cinematoplastic  Amputations. — (See  p.  256.) 

Mortality  after  Amputation. — Although  this  depends  much  more  on 
the  condition  of  the  patient  than  on  any  other  single  factor,  it  is 
nevertheless  proper  for  the  surgeon  to  be  familiar  with  the  relative 
mortality  of  amputations  for  injury  and  for  disease;  and,  in  cases 
of  injury,  with  that  which  accompanies  primary,  intermediate,  and 
secondary  operation;  as  well  as  the  average  mortality  which  attends 
amputation  in  different  regions  of  the  body.  Primary  amputations 
are  those  done  before  the  inflammatory  process  has  had  time  to 
develop — generally  speaking,  those  done  within  twelve  hours  of 
injury;  intermediate  amputations  are  those  done  during  the  height  of 
the  inflammatory  process;  and  secondary  amputations  are  those 
performed  after  its  subsidence,  when  the  operation  resembles  that 
done  for  disease.  As  a  rule,  the  lowest  mortality  attends  primary 
amputations;  and  though  since  the  introduction  of  antiseptic  methods 
there  is  less  inflammatory  reaction  than  formerly,  nevertheless 
intermediary  amputations  still  give  the  highest  mortality.  In  the 
case  of  secondary  amputation  the  results  are  not  so  good  as  they 
seem,  many  patients  being  too  shocked  for  primary  amputation, 
and  dying  before  secondary  amputation  can  be  attempted. 

It  has  usually  been  taught,  and  it  is  still  stated  by  many  surgeons, 


Fig.  166. — End-bearing  stump 
(aperiosteal  method  of  Bunge). 
Patient  bearing  all  his  weight  on 
the  stump  twenty-five  days  after 
amputation.     Episcopal  Hospital. 


224  AMPUTATIONS 

that  amputations  tor  disease  are  attended  by  a  much  lower  death 
rate  than  those  for  injury.  While  this  was  perfectly  true  before  the 
general  adoption  of  antiseptic  methods  and  modern  methods  of 
treating  shock  and  hemorrhage,  I  believe  the  relation  is  now  reversed. 

Treatment  of  Crushed  Limbs. — The  first  thing  to  do  is  to  control 
hemorrhage  and  combat  shock.  The  limb  should  be  held  vertically, 
and  an  Esmarch  band  applied  as  near  to  the  crushed  area  as  practicable; 
the  foot  of  the  bed  should  be  raised,  and  in  cases  of  grave  anemia  the 
other  extremities  should  be  bandaged  from  the  periphery  toward 
the  trunk  (auto-transfusion).  The  application  of  external  heat,  and 
other  methods  detailed  at  p.  184,  should  be  employed  for  shock. 
If  any  vessels  can  be  recognized  in  the  wound  they  should  be  ligated. 
Amputation  should  be  done  as  soon  as  the  -patient  reacts,  or  at  once  if 
the  shock  is  not  marked.  If  reaction  once  occurs  no  delay  in  ampu- 
tating should  be  allowed,  as  the  improvement  frequently  is  only  fleeting, 
unless  the  mangled  limb  is  removed.  The  Esmarch  band  should  not 
be  left  in  one  place  more  than  four  or  five  hours;  sometimes,  on  removing 
it,  no  further  bleeding  will  occur;  but  usually  a  little  ooze  persists, 
and  the  band  should  be  re-applied  higher  on  the  limb.  In  a  few 
hours  its  position  should  again  be  shifted  (applying  a  second  before 
removing  the  first,  if  necessary),  since  in  this  way  it  is  possible  to 
keep  the  bleeding  checked  without  endangering  the  vitality  of  the 
parts  above  the  wound. 

If  the  patient  does  not  react,  or  if,  in  spite  of  the  skilful  application 
of  the  Esmarch  band,  oozing  of  blood  persists,  and  seems  to  prolong 
shock,  the  surgeon  must  consider  whether  the  mere  presence  of  the 
mangled  extremity  is  not  detrimental,  and  whether  by  resorting  to 
amputation  at  once  he  will  not  obviate  the  tendency  to  death  better 
than  by  delay.  These  are  the  cases  which  suffer  from  true  toxemic 
shock  (p.  181).  In  such  cases  delay  is  fatal  with  extremely  few  excep- 
tions; but  by  prompt  operation,  even  under  desperate  circumstances, 
a  life  is  occasionally  saved. 

SPECIAL  AMPUTATIONS. 

Amputations  of  the  Hand. — Though  removal  of  a  portion  of  the 
hand  is  required  frequently,  the  surgeon  should  exercise  the  utmost 
conservatism;  no  artificial  contrivance  can  be  as  useful  as  the  human 
hand,  and  though  amputation  of  a  portion  of  it  is  often  a  less  tedious 
and  more  brillant  operation  than  partial  excision  and  careful  suture, 
yet  judicious  attempts  at  the  latter  are  not  seldom  attended  by 
gratifying  results  (Figs.  120  and  121). 

Amputation  of  the  Fingers. — No  tourniquet  is  required,  and  local 
anesthesia  usually  is  sufficient.  This  is  secured  by  injections  at  four 
points  around  the  base  of  the  finger,  blocking  the  digital  nerves. 
It  is  best  to  remove  the  fingers  at  a  joint,  but  amputation  is  fre- 
quently done  through  the  proximal  or  middle  phalanx  of  the  index 
and  fifth  fingers;  this  is  then  divided  with  a  small  saw  or  cutting 


SPECIAL  AMPUTATIONS 


225 


forceps.  The  middle  and  ring  fingers  are  of  comparatively  little 
use,  unless  part  of  the  middle  phalanx  is  retained  (Fig.  167);  hence 
it  is  better  to  amputate  at  the  metacarpal  joint  than  to  save  only 
part  of  the  proximal  phalanx,  unless  the  tendons  can  be  sutured 
to  each  other  over  the  end  of  the  stump.     The  position  of  the  joints 


Fig.  167. — Tendinous  insertions  in  the  middle  finger:  a,  deep  flexor;  6,  superficial 
flexor;  c,  extensor;  d,  lumbrical;  c,  extensor  carpi  radialis  brevior.  Note  the  uselessness 
of  the  proximal  phalanx  (2),  unless  the  insertion  of  the  superficial  flexor  tendon  is 
retained  in  the  middle  phalanx  (3),  or  unless  b  is  sutured  to  c  over  the  end  of  2.  (After 
Waring.) 

must  be  borne  in  mind  (Fig.  168),  the  usual  error  being  to  expect  to 

find  them  too  high.     In  amputation  by  the  racket-shaped  incision 

(Fig.    169),  the  first  incision,  on  the  dorsum,  opens  the  joint,  and 

as  the  finger  is  sharply  flexed  the  lateral  ligaments  are  divided,  and 

the  palmar  flap  is  formed  by  passing  the  narrow-bladed  knife  between 

the  ends  of  the  bones  and  cutting 

from  within  outward.    It  is  easier  /p^         £ 

to  preserve  the  tendons  if  a  short 

extensor  and  long    flexor  flap  are 

employed.     The  digital  arteries  are 

ligated,    the    flexor    and    extensor 

tendons    sutured    to    each    other 

by  buried  sutures;  and  the  stump 


Fig.  168. — The  finger-joints. 


Fig.  169. — Amputation  of  the  fingers  by 
the  racket-shaped  incision  and  by  antero- 
posterior flaps. 


is  closed  by  bringing  up  the  palmar  flap  and  suturing  it  transversely. 
This  is  known  as  the  "poor  man's  amputation"  because  the  scar  is 
carried  away  from  the  palmar  surface  and  the  stump  is  covered  with 
the  tough  palmar  skin.  If  the  palmar  surface  is  destroyed  by  disease 
or  injury,  a  dorsal  flap  may  be  used  ("rich  man's  amputation"). 
Two  lateral  flaps  are  sometimes  employed. 
15 


226 


AMPUTATIONS 


In  amputation  at  the  metacarpo-phalangeal  joints  the  racket  method 
is  to  be  preferred;  in  the  case  of  the  index  and  fifth  fingers,  the  handle 
of  the  racket  is  placed  on  the  radial  and  ulnar  borders  of  the  joint, 
instead  of  on  the  dorsum.  The  head  of  the  metacarpal  bone  of  the 
two  middle  fingers  sometimes  is  removed  for  cosmetic  reasons.  Am- 
putation of  the  thumb  is  done  by  making  a  palmar  flap  whenever  pos- 


Fig.  170. — Partial  amputation  of  right  hand  for  crush.     Everything  but  the 
thumb  removed.     Episcopal  Hospital. 

sible.  Amputations  through  the  metacarpal  bones  are  done  by  antero- 
posterior flaps,  saving  as  much  of  the  palm  as  possible,  and  making  the 
necessary  incisions  on  the  back  of  the  hand.  Owing  to  the  variety 
and  irregularity  of  the  injuries  to  the  soft  parts  and  bones  in  such 
cases,  each  one  is  a  rule  to  itself,  and  the  surgeon  must  exercise  his 
ingenuity  in  saving  whatever  may  prove  useful,  and  securing  skin 
flaps  in  any  way  possible  (Fig.  170). 


Fiu.  171. — Anterior-posterior  skin  flaps,  two  inches  below  elbow.     Episcopal  Hospital. 


Amputations  through  the  Wrist-joint  are  seldom  employed;  a  long 
palmar  flap  should  be  cut,  and  the  triangular  cartilage  should  be 
retained,  so  as  to  aid  in  the  preservation  of  rotation. 

Amputations  of  the  Forearm. — In  the  lower  half  of  the  forearm 
I  think  the  circular  method  is  the  best  form  of  amputation,  while 
below  the  elbow  the  modified  circular,  with  antero-posterior  skin 
flaps  is  quite  satisfactory  (Fig.  171).  Some  surgeons  employ  Teale's 
method  above  the  wrist:  in  this  two  rectangular  flaps  are  formed,  the 
width  of  each  being  half  the  circumference  of  the  limb ;  the  longer  flap 
(formed  from  the  flexor  surface)  is  exactly  square,  while  the  shorter 
flap  is  only  one-fourth  as  long  (Fig.  172). 


SPECIAL  AMPUTATIONS  227 

Amputation  at  the  Elbow. — This  may  be  done  by  the  oval  method, 
taking  a  long  skin  flap  from  the  thick  skin  covering  the  upper  part 
of  the  ulna;  or  by  antero-posterior  flaps,  the  anterior  being  longer 
and  including  the  muscular  masses  arising  from  the  condyles  as  well 
as  the  brachialis  anticus.  The  joint  is  entered  just  above  the  head 
of  the  radius. 

Amputation  through  the  Arm. — The  circular  method  is  suitable 
for  any  level  up  to  the  insertion  of  the  deltoid;  above  this  point  lateral 
flaps  are  to  be  preferred.  Injury  by  the  saw  to  the  musculo-spiral 
nerve  is  to  be  avoided  in  amputations  of  the  middle  third;  and  the 
incisions  in  the  upper  third  should  respect  the  circumflex  nerve  as 
it  enters  the  posterior  surface  of  the  deltoid.  In  cases  of  high  ampu- 
tation of  the  arm  the  tourniquet  is  applied  with  the  screw  over  the 
acromion  and  a  large  pad  in  the  axilla  over  the  vessels  which  are 
thus  compressed  against  the  head  of  the  humerus  as  the  arm  is  well 
abducted;  or  the  bloodless  method  of  Wyeth  for  amputation  at  the 
shoulder-joint  may  be  adopted. 


Fig.  172. — Teale's  method  of  amputation. 

Amputation  at  the  Shoulder- joint. — (Morand,  before  1715.)  Hemos- 
tasis  is  best  secured  by  Wyeth's  method  (1889) :  two  long  steel 
pins  are  used,  one  entering  in  front  of  the  acromion  and  travers- 
ing the  anterior  axillary  fold,  to  emerge  close  to  the  chest;  while 
the  other  passes  from  behind  the  acromion  to  the  border  of  the 
posterior  axillary  fold,  also  close  to  the  chest.  The  points  of  these 
pins  should  be  guarded  by  sterile  corks.  An  Esmarch  band 
is  then  wrapped  tightly  three  or  four  times  around  the  shoulder, 
passing  from  above  the  acromion  around  the  armpit  between 
the  pins  and  the  chest  (Fig.  173).  This  band  is  effectually  pre- 
vented from  slipping  down  by  the  steel  pins,  and  the  surgeon  can 
form  his  flaps  in  any  fashion  below  them.  If  these  pins  are  not 
available,  the  surgeon  may  have  the  subclavian  artery  compressed; 
or,  which  is  better,  may  cut  down  in  the  axilla  and  do  a  preliminary 
ligation  of  the  axillary  artery  in  its  third  portion. 

The  only  form  of  amputation  habitually  practised  at  the  shoulder- 
joint  is  the  racket  method,  though  it  has  many  modifications,  known 
by  various  names.  The  operation  of  Larrey  (1817),  (external  racket 
method),  is  now  very  seldom  employed  (Fig.  174).  In  Spence's  ampu- 
tation (1807),  (anterior  racket  method)  the  incision  begins  midway 


228 


AMPUTATIONS 


between  the  acromion  and  the  coracoid,  where  the  point  of  an  oval  is 
formed,  then  passes  down  nearly  to  the  insertion  of  the  deltoid,  and 
there  encircles  the  arm  transversely  (Fig.  175).     Dupuytren's  ampu- 


Fig.  173. — Wyeth's  pins  applied  for 
amputation  at  the  shoulder. 


Fig.  174. — Incisions  for  amputation  at 
the  shoulder  by  Larrey's  method  (external 
racket). 


tation  (1812),  by  a  large  deltoid  flap,  originally  was  performed  by 
transfixion:  the  knife  entered  at  the  front,  just  within  the  acromion, 
and  its  point  emerged  behind  at  the  level  of  the  spine  of  the  scapula; 
the  flap  extended  down  almost  to  the  insertion  of  the  deltoid.  After  dis- 


Fig.  175. — Incisions  for  amputation  at 
the  shoulder  by  Spence's  method  (ante- 
rior racket). 


Fig.  176. — Incisions  for  amputation  at 
the  shoulder  by  Dupuytren's  method 
(external  flap). 


articulation  a  short  internal  flap  was  cut  from  within  outward  (Fig.  176) . 
A  form  of  amputation  midway  between  these  two  extremes  (Spence 
and  Dupuytren)  may  be  termed  the  lateral  flap  method,  the  internal 


SPECIAL  AMPUTATIONS 


229 


flap  being  very  short,  and  the  external  being  formed  by  an  incision 
beginning  as  in  Dupuytren's  and  Spence's  methods,  but  not  extending 
so  high  posteriorly  as  the  former. 

Lateral  Flap  Method. — The  knife  is  entered  between  the  eoracoid 
and  acromion  processes,  and  cutting  through  all  the  tissues  down 
to  the  muscle  is  carried  downward  in  a  broad  sweep,  nearly  to  the 
insertion  of  the  deltoid,  and  up  again  as  far  as  the  posterior  axillary 
fold.  The  flap  thus  marked  out  is  deepened  to  the  bone,  and  raised 
so  as  to  expose  the  tuberosities  of  the  humerus.  With  the  arm  of 
the  patient  held  close  against  his  chest,  and  rotated  out  as  far  as  it 
will  go,  the  point  of  the  amputating  knife  opens  the  capsule  by 
following  the  long  tendon  of  the  biceps  into  the  joint,  and  then 
detaches  the  subscapularis,  attached  to  the  lesser  tuberosity,  and 
severs  the  long  head  of  the  bi- 
ceps. The  arm  is  then  forcibly 
rotated  inward,  and  the  muscles 
attached  to  the  greater  tuber- 
osity are  severed.  The  head  of 
the  bone  then  drops  from  the 
glenoid  cavity,  and  may  be  fur- 
ther freed  by  cutting  the  mus- 
cles attached  to  the  bicipital 
groove.  The  amputating  knife 
is  then  passed  across  the  joint 
between  the  upper  end  of  the 
humerus  and  the  axilla,  and  the 
axillary  tissues  are  cut  from 
within  outward.  After  ligating  the  vessels  the  Esmarch  band  and  the 
pins  are  removed,  the  muscles  of  the  two  flaps  are  sutured  to  each 
other,  and  the  skin  closed,  with  provision  for  drainage  from  the  two 
ends  of  the  incision. 

This  form  of  amputation  may  be  very  quickly  performed,  and 
it  leaves  a  very  excellent  stump  (Fig.  177).  Its  advantages  are  (1) 
the  first  incision  is  the  same  as  that  used  for  excision  of  the  shoulder- 
joint,  and  permits  inspection  of  the  parts  before  the  amputation  is 
performed;  (2)  the  posterior  circumflex  artery  and  circumflex  nerve 
are  not  divided,  if  the  knife  is  kept  close  to  the  bone  in  detaching 
the  deltoid  flap;  (3)  either  the  external  or  internal  flap  may  be  re- 
trenched at  the  expense  of  the  other,  in  case  of  injury  or  disease 
invading  one;  (4)  in  emergencies  the  entire  operation,  up  to  the 
division  of  the  inner  flap,  may  be  completed  almost  bloodlessly 
without  the  use  of  a  tourniquet;  and  the  main  vessels  can  readily 
be  controlled  by  the  fingers  of  an  assistant  before  the  inner  flap  is 
severed;  or  the  third  portion  of  the  axillary  artery  may  be  ligated 
through  the  first  incision,  before  raising  the  external  flap  or  dis- 
articulating; finally  (5)  it  is  more  nearly  universally  applicable  than 
any  other  method  of  shoulder- joint  amputation. 


Fig.  177. — Stump  resulting  from  latera 
flap  method  of  shoulder  amputation  (modi- 
fied Dupuytren's).     Episcopal  Hospital. 


230 


AMPUTATIONS 


Amputation  above  the  Shoulder. — The  interscaputo-thoradc  ampu- 
tation   (Berger's  operation,    1SS7)  comprising  removal  of  the  entire 

upper  extremity,  is  employed  usually 
for  disease,  especially  sarcomas  of  the 
shoulder  or  scapula,  though  it  is  occa- 
sionally required  for  injury.  The  oper- 
ation is  best  performed  by  opening  the 
sterno-clavicular  joint,  raising  the  clavi- 
cle (Le  Conte,  1899),  and  detaching  the 
pectoralis  minor  from  the  coracoid;  then 
the  subclavian  artery  and  vein  are  doubly 
ligated  outside  of  the  scalenus  anticus, 
and  divided;  the  brachial  plexus  is  next 
cut;  the  transversus  colli  and  supra- 
scapular arteries  are  ligated  and  divided, 
and  finally  the  scapula  is  dissected  away 
from  the  chest.  The  incisions  used  are 
shown  in  Fig.  178.  Berger  (1905)  col- 
lected ninety-four  cases  of  this  operation, 
with  eight  deaths,  a  mortality  of  8.5 
per  cent.;  in  the  twenty-five  cases  in  which  the  tumor  originated 
in  the  scapula  there  were  five  deaths,  and  only  three  deaths  among 
the  sixty-nine  cases  of  sarcoma  of  the  humerus. 

Amputations  of  the  Foot. — The  yhalanges  may  be  amputated  by 
an  oval  incision,  with  a  plantar  flap;  or,  preferably,  by  antero- 
posterior flaps.  The  heads  of  the  metatarsal  bones  should  be 
retained  whenever  possible,  as  they  afford  great  support  in  walk- 


Fig.  17S. — Incisions    for    intersca 
pulo-thoracic  amputation. 


Fig.  179. — The  tarsal  joints:  A,  astragalus;  Ca,  calcaneum;  S,  scaphoid;  C,  cuboid; 
1,  2,  3,  cuneiform  bones.  Note  the  irregularity  of  Lisfranc's  joint  (between  the  tarsus 
and  metatarsus).  Chopart's  joint  is  between  the  astragalus  and  calcaneum  posteriorly, 
and  the  scaphoid  and  cuboid  anteriorly.  The  subastragalar  joint  includes  the  astragalo- 
scaphoid  joint  as  well  as  the  astragalo-calcanean. 


ing.  A  single  metatarsal  bone,  with  its  annexed  digit,  may  be  removed 
by  a  dorsal  incision.  Amputations  through  the  metatarsal  bones 
are  sometimes  performed  for  gangrene  following  frost-bite;  a  long 
plantar  and  short  dorsal  flap  are  used.  Amputation  at  the  tarso- 
metatarsal joint  (Lisfranc,  1815)  is  difficult  to  perform,  and  is 
seldom  employed  (Fig.  179).  To  avoid  the  difficulties  of  dis- 
articulation Hey  (1799)  sawed  off  the  projecting  internal  cuneiform, 
while  Skey  (1850)  removed  the  base  of  the   second   metatarsal  by 


SPECIAL  AMPUTATIONS 


231 


cutting  forceps.  It  is  better  to  saw  through  the  foot  at  any  level 
required  by  the  length  of  available  skin  flaps  (Hancock).  Ampu- 
tation at  the  medio-tarsal  joint  (Chopart,  1792)  is  performed  thus: 
a  transverse  incision,  convex  forward,  is  made  across  the  dorsum 
of  the  foot,  from  a  point  midway  between  the  external  malleolus 
and  the  tuberosity  of  the  fifth  metatarsal,  to  a  point  half  an  inch 
behind  the  tubercle  of  the  scaphoid;  the  plantar  flap  extends  from 
the  same  points  as  far  forward  as  the  line 
of  the  metatarso-phalangeal  joints.  The  usual 
error  is  to  make  this  flap  too  short.  By  for- 
cing the  foot  downward,  after  making  the 
dorsal  flap,  the  joint  between  the  calcaneum 
and  cuboid  is  easily  opened  on  the  outer  side; 
and  the  disarticulation  is  completed  by  pass- 
ing between  the  astragalus  and  scaphoid. 
Though  the  scaphoid  has  repeatedly  been 
left,  unintentionally,  it  has  not  interfered 
with  the  result.  The  tibialis  anticus  tendon 
should  be  sutured  over  the  end  of  the  stump 
to  the  plantar  tissues.  Careful  dressing  and 
after-treatment  are  required  to  keep  the  calf 
muscles  from  drawing  the  cicatrix  on  to  the 
sole  of  the  foot.  The  patient  walks  with 
the  ankle-joint  in  slight  plantar  flexion  (Fig. 
180). 

Amputation  at  the  Ankle-joint  (Syme, 
1843),  including  removal  of  the  malleoli,  is 
performed  by  making  a  heel  flap  by  cutting 
across  the  sole  from  one  malleolus  to  the 
other.  Subastragalar  amputation  (Textor, 
1841)  retains  the  motions  of  the  ankle-joint, 
and  greater  length  of  limb. 

Pirogoff's  Amputation  (1854). — In  this  operation  all  the  foot  is 
removed,  except  the  posterior  part  of  the  calcaneum,  which,  still 
attached  to  the  tendo  Achillis  and  covered  by  the  tissues  of  the  heel, 
is  brought  up  and  applied  to  the  sawn  surfaces  of  the  tibia  and  fibula 
(Fig.  181).  The  plantar  flap  is  formed  by  cutting  across  the  sole  from 
just  in  front  of  the  external  malleolus  to  just  below  the  internal 
malleolus;  the  dorsal  flap  is  slightly  convex  forward  across  the  front 
of  the  ankle-joint  (Fig.  182).  The  malleoli  are  cleared,  carefully  pre- 
serving the  calcaneal  branches  of  the  posterior  tibial  artery,  and  the 
leg  bones  are  sawed  just  above  the  articular  surface.  The  calcis  is 
sawed  obliquely  from  above  downward  and  forward.  This  amputa- 
tion preserves  almost  the  normal  length  of  the  extremity  (lost  in 
Syme's  amputation),  but  is  difficult  to  perform,  and  makes  a  less 
useful  stump  than  Chopart's. 

None  of  these  foot  amputations  are  in  very  good  repute  in  this 
country,  where  both  patient  and  surgeon  usually  prefer  amputation 


Fig.  180.— Stump  thirty- 
two  years  after  Chopart 
amputation  (in  1877)  by 
the  late  Prof.  Ashhurst. 
Episcopal  Hospital. 


232 


AMPUTATIONS 


about  the  middle  of  the  leg,  since  a  better  prosthesis  is  available. 
The  English  think  highly  of  Syme's,  and  the  French  of  Chopart's 
amputation;  my  own  experience  inclines  me  to  prefer  Chopart's  to 
any  amputation  of  the  foot  posterior  to  one  through  the  metatarsals; 
rather  than  do  a  Pirogoff  or  Syme,  I  would  amputate  the  leg. 

Amputation  of  the  Leg. — In  the 
lower  third  of  the  leg,  antero-pos- 
terior  flaps  are  to  be  preferred. 
Teale's  method  (1858)  produces 
an  excellent  stump  (Fig.  172).  In 
the  middle  and  upper  leg  the  lat- 
eral flap  method  of  Sedillot  (1840) 
as  modified  by  J.  Ashhurst,  Jr. 
(1889),  is  better:  The  knife  is 
entered  on  the  inner  side  of  the 
spine  of  the  tibia,  and  passes  down- 
ward for  about  three  inches,  then 
curves  backward,  outlining  a  long 
flap  and  terminates  diametrically 
opposite  the  point  of  beginning;  a 


Fig.  181. — Skiagraph  of  stump  of  Piro- 
goff operation.  (Case  of  Dr.  H.  C. 
Deaver.)     Episcopal  Hospital. 


Fig.  182. — Skin  incision  for  Syme's  and 
Pirogoff 's  amputations. 


short  internal  flap  is  then  formed  (Fig.  183).  The  cicatrix  is  carried 
to  the  inner  side  of  the  stump,  and  the  outer  flap  covers  the  spine  of 
the  tibia  (Fig.  184).  If  the  skin  on  the  front  of  the  leg  is  deficient,  a 
long  posterior  flap  may  be  used  (Henry  Lee,  1865),  preferably  includ- 
ing only  the  gastrocnemius  muscle  (J.  Ashhurst,  Jr.,  1881). 

Amputation  at  the  Knee. — A  distinction  is  made  between  amputa- 
tions at  the  knee-joint,  which  are  pure  disarticulations,  and  ampu- 
tations at  the  knee,  in  which  a  section  is  removed  from  the  femoral 
condyles.  Amputations  at  the  knee-joint  are  prone  to  infection,  and 
leave  a  bulky  stump,  difficult  to  fit  with  an  artificial  limb.  Two 
methods  are  in  use,  a  long  anterior  flap  method,  and  a  lateral  flap 
method;  the  latter  is  more  applicable  to  disarticulations,  when  the 
cicatrix  falls  between  the  condyles  (Stephen  Smith,  1870).  But  the 
anterior  flap  method  is.  better  even  in  such  cases.  If  the  patella  is 
retained  its  articular  surface  may  be  removed  by  a  saw,  and  applied 


SPECIAL  AMPUTATIONS 


233 


to  the  sawn  surface  of  the  femoral  condyles  (transcondylar  ampu- 
tation of  Gritti,  1857);  or  to  that  of  the  femoral  shaft  {supracondylar 
amputation  of  Stokes,  1870)  (Fig.  185). 


Fig.  184. — Stump  of  leg  eight  weeks 
after  amputation  by  Ashhurst's  modifica- 
tion of  Sedillot's  method.  Episcopal 
Hospital. 


Fig.  183. — Amputation  of  leg  by 
long  external  and  short  internal  flaps. 
(J.  Ashhurst,  Jr.'s  method.) 


Fig.  185. — Stokes'  osteoplastic  supra- 
condylar knee  amputation,  patella  utilized : 
shaded  parts  are  those  brought  in  apposi- 
tion.     (Farabeuf.) 


Amputation  of  the  Thigh. — The  circular,  modified  circular,  and 
flap  methods  all  produce  an  excellent  stump  in  the  thigh.  The  circular 
is  best  whenever  there  is  a  choice.  If  flaps  are  used,  the  posterior 
should  be  cut  sufficiently  long.  The  greater  retraction  of  muscles 
in  the  posterior  flap  carries  the  cicatrix  away  from  the  face  of  the 
stump  (Fig.  186). 

Amputation  at  the  Hip-joint  (H.  Thomson  before  1777). — Hemo- 
stasis  is  secured  by  Wyeth's  method  (1890):  Two  steel  pins  are 
used,  each  T3g-  of  an  inch  in  diameter,  and  ten  inches  long;  one  pin 
is  introduced  close  to  the  spine  of  the  pubis,  and  after  traversing  the 
adductor  tendons  emerges  just  below  the  tuberosity  of  the  ischium; 
the  other  pin  enters  below  and  within  the  anterior  superior  spine  of 
the  ilium,  traverses  the  gluteal  muscles  for  about  8  cm.,  and  emerges 


234 


AMPUTATIONS 


well  above  the  level  of  the  great  trochanter;  the  points  of  the  pins 
are  immediately  shielded  by  corks.  A  compress  of  gauze,  two  inches 
thick  and  four  inches  square,  is  laid  over  the  femoral  vessels  at 
the  brim  of  the  pelvis,  and  an  Esmarch  hand  is  wrapped  very  tightly 
two  or  three  times  around  the  hip  between  the  steel  pins  and  the 
pelvis  (Fig.  1ST). 


B 

"y^^Hi^ 

Fig.  1S6. — Amputation  of  right  thigh 
(anterior-posterior  flaps).  Episcopal 
Hospital. 


Fig.  187. — Wyeth's  pins,  and  Esmarch 
band,  for  hemostasis  during  amputation  at 
the  hip-joint. 


Antero-posterior  Flap  Method  (Guthrie,  1815). — The  flaps  are  cut 
from  without  inward,1  with  a  moderately  short  knife;  the  posterior 
is  formed  first,  the  incision  commencing  above  the  trochanter,  and 
crossing  the  back  of  the  thigh  in  a  curved  line  convex  downward,  to 
a  point  in  front  of  the  tuber  ischii;  the  anterior  flap  is  then  outlined, 
extending  at  least  five  inches  below  the  joint  (Fig.  188).  These  flaps 
being  dissected  up  and  the  joint  exposed,  it  is  opened  in  front,  the  femur 
being  forcibly  abducted  and  hyper-extended,  bringing  the  ligamentum 
teres  into  view;  when  this  has  been  cut  and  the  remainder  of  the 
capsule  divided,  any  fibers  on  the  back  of  the  joint  are  severed,  and 
the  limb  removed. 

In  cases  where  Wyeth's  method  of  hemostasis  is  not  available, 
and  where  Momburg's  method  (p.  235)  is  not  employed,  the  sur- 
geon may  adopt  either  preliminary  ligation  of  the  femoral  vessels, 
by  an  anterior  racket  incision  (Larrey,  1817),  opening  the  joint 
from  the  front  and  dividing  the  remaining  tissues  posteriorly  from 
within  outward;2  or  he  may  adopt  DiefTenbach's  method  (1827), 
consisting  of  circular  amputation  of  the  thigh  followed  by  excision 
of  the  head  of  the  femur  through  an  outer  longitudinal  incision;  or 
following  Brashear's  (1806)  and  Fourneaux-Jordan's  (1879)  method 

1  Guthrie  cut  them  by  transfixion. 

2  This  is  the  "extirpation  method"  of  Kocher,  permitting  careful  dissection  of 
malignant  disease,  and  clamping  and  ligating  every  vessel  as  it  is  cut.  It  was 
used  habitually  by  Verneuil  (1877)  in  all  large  amputations. 


SPECIAL  AMPUTATIONS 


235 


as  modified  by  Senn  (1893)  may  first  disarticulate  through  an  external 
incision  and  then,  puncturing  the  tissues  on  the  inner  side  of  the 
thigh,  introduce  a  double  elastic  tube,  and  compress  in  this  way  the 
tissues  of  both  anterior  and  posterior  flaps  before  removing  the  limb. 
Compression  by  a  forceps  tourniquet,  somewhat  like  the  forceps  used 
for  intestinal  anastomosis,  may  also  be  employed  (Lynn  Thomas, 
1898).  The  mortality  of  hip-joint  amputation  is  now  about  8  per 
cent,  in  disease,  and  16  per  cent,  in  traumatic  cases  (Wyeth,  1910), 
this  vast  improvement  in  the  results  being  due  chiefly  to  improve- 
ments in  methods  of  hemostasis. 


Fig.  188. — Incisions  for  amputation 
at  the  hip-joint  by  antero-posterior 
flaps.    (Guthrie's  method.) 


Fig.  189. — Incision  for  interilio-abdominal 
amputation.      (Babcock.) 


Interilio-abdominal  Amputation  (Billroth,  1885). — The  incisions 
used  by  Babcock  (1918)  are  shown  in  Fig.  189.  The  horizontal  and 
descending  rami  of  the  pubes  are  divided,  and  the  ilium  is  sawed 
through  just  in  front  of  the  sacro-iliac  joint,  the  entire  intervening 
portion  of  the  pelvis  being  removed.  Pringle  (1916)  has  collected 
43  cases,  with  a  death-rate  of  58  per  cent.  He  has  done  5  such 
operations  himself,  only  1  patient  dying  (shock) ;  he  prefers  to  clamp 
and  cut  the  vessels  as  they  are  encountered.  Pagenstecher  (1909) 
and  Bier  have  used  successfully  Momburg's  method  of  hemostasis  (1908) : 
This  had  been  employed  up  to  1909  with  success  in  over  thirty  oper- 
ations of  various  kinds.  It  consists  in  applying  an  Esmarch  band  or 
thick  rubber  tube  (size  of  the  finger)  four'  or  five  times  so  tightly  around 
the  waist,  between  costal  arch  and  iliac  crests,  as  to  stop  pulsation  in 
both  femoral  arteries;  the  band  is  applied  only  after  the  patient  is 
anesthetized,  and  before  it  is  removed  the  patient  is  inverted  and  an 
elastic  band  applied  around  the  base  of  each  lower  extremity,  so  as  to 
prevent  sudden  anemia  of  the  heart  when  the  waist  band  is  removed. 


CHAPTER   IX. 
RE< '( INSTRUCTIVE  SURGERY. 

The  term  Reconstructive,  or  Plastic  Surgery,  covers  a  wide  range  of 
surgical  procedures  designed  to  restore  or  improve  the  function  or 
appearance  of  a  part,  deficient  congenitally  or  through  disease  or 
injury.  Until  within  a  few  years  its  field  wras  limited  to  the  skin 
and  subcutaneous  tissues  (including  mucous  membrane),  and  to  this 
department  the  name  Plastic  Surgery  (anaplasty)  strictly  applies. 
But  recently  the  formation  of  new  joints  (arthroplasty),  transplanta- 
tion of  bone,  cartilage,  fascia,  tendon,  etc.,  and  cinematoplastic 
amputations  have  been  done. 

These  various  operations  may  be  classified  as  follows: 

1.  Anaplasty  by  .simple  approximation  as  after  excision  of  any 
tumor  in  which  the  wound  edges  can  be  brought  together,  if  necessary 
by  undermining;  in  the  operation  for  hare-lip,  etc. 

2.  Anaplasty  by  transfer  of  flaps  from  the  immediate  neighborhood, 
by  gliding,  stretching,  etc.,  as  in  operations  for  deforming  cicatrices 
from  burns,  and  in  the  Indian  method  of  rhinoplasty  (p.  667),  in 
muscle   transplantation,   etc. 

3.  Anaplasty  by  transfer  of  flaps  from  a  distance: 

(a)  By  one  migration,  as  in  the  Italian  method  of  rhinoplasty  (p.  668). 

(b)  By  successive  migrations  (method  of  Roux),  as  from  the  abdomen 
to  the  arm,  and  then  from  the  arm  to  the  face. 

4.  Anaplasty  by  readjustment  of  totally  severed  parts,  including  skin- 
grafting,  transplantation  of  fascia,  bones,  joints,  etc. 

SKIN-GRAFTING. 

This,  which  is  the  simplest  form  of  plastic  surgery,  will  be  con- 
sidered first.  In  cases  of  extensive  granulating  areas  resulting  from 
burns  or  other  causes,  this  plan  often  not  only  accelerates  healing, 
but  may  be  absolutely  necessary  to  bring  it  about.  For  the  grafts 
to  "take"  well  it  is  essential  that  the  granulating  surface  approach 
in  type  to  that  of  the  "healthy  ulcer"  (p.  53).  There  are  three 
principal  methods  of  skin-grafting,  known  by  the  names  of  Reverdin 
(1869),  Thiersch  (1874),  and  Wolfe  (1875)  or  Krause  (1893).  In 
all  of  these  methods  the  granulating  surfaces  must  first  be  prepared 
for  the  reception  of  the  grafts.  If  the  surface  is  suppurating,  it  is 
useless  to  attempt  grafting.  When  it  has  been  rendered  aseptic  and 
there  is  no  discharge,  the  area  is  ready  for  grafting.  Needless  to  say 
syphilitic,  malignant  or  other  ulcerating  surfaces  are  not  suitable  for 
(236) 


SKIN-GRAFTING  237 

skin-grafting,  nor  is  any  surface  which  must  bear  weight,  such  as 
the  end  of  an  amputation  stump.  Boykin  (1916)  reports  success 
from  prepara  ion  for  two  days  with  dressings  kept  constantly  moist 
with  warm  sodium  bicarbonate  solution  (2  per  cent.). 

The  best  sites  from  which  to  obtain  grafts  are  the  adductor  surfaces 
of  the  thighs,  the  inner  surfaces  of  the  arms,  and  the  lateral  abdominal 
and  thoracic  walls;  hairy  skin  is  not  suitable  for  grafting,  as  apart 
from  the  deformity  which  might  result  from  reproduction  of  the  hair, 
it  is  difficult  to  sterilize,  and  less  apt  to  grow  successfully  than  more 
delicately  formed  skin.  The  region  from  which  the  grafts  are  taken 
also  must  be  prepared  as  for  an  aseptic  operation.  Antiseptic  methods 
are  not  successful. 

Whenever  possible  autografts  (from  the  patient's  own  body)  should 
be  employed.  Homografts  (from  another's  body)  are  much  less  likely 
to  grow,  and  should  be  used  only  when  the  recipient  is  so  extensively 
affected  as  to  render  any  additional  tax  on  his  healing  powers  unwise. 


Fig.  190. — Skin-grafting  by  Reverdin's  method,  in  a  case  of  burns  of  leg.     The  white 
spots  on  the  surfaces  of  the  ulcers  are  islets  of  new-formed  skin.    Episcopal  Hospital. 

Reverdin's  Method. — Minute  particles  of  the  cuticle  are  raised  on 
the  point  of  a  needle,  cut  off  with  a  sharp  scalpel,  and  at  once  trans- 
ferred to  the  granulating  surface,  previously  prepared.  As  many 
such  grafts  as  may  be  required  (a  score  or  more)  are  applied  with  the 
epidermic  side  upward,  at  close  intervals;  gently  pressed  down  on 
the  granulations,  and  held  in  place  by  covering  the  entire  area  with 
wide  meshed  paraffined  gauze,  over  which  in  turn  may  be  placed  gauze 
moistened  in  saline  or  2  per  cent,  sodium  bicarbonate  solution.  The 
part  is  suitably  splinted,  and  need  not  be  dressed  for  four  or  five 
days,  when  it  will  be  found  that  many  of  the  grafts  have  taken,  and 
may  be  recognized  as  minute  islets  of  bluish-white  epiderm  growing 
in  the  center  of  the  granulating  area  (Fig.  190).  In  time  these  islets 
coalesce,  and  a  number  of  small  granulating  areas  surrounded  by 
epiderm  replace  the  one  large  surface. 

This  method  is  suitable  when  only  small  areas  are  to  be  covered. 
The  donor  does  not  require  an  anesthetic. 

Thiersch's  Method. — Long  strips  of  epiderm,  with  only  the  most 
superficial  layer  of  the  cutis,  are  cut  by  means  of  a  very  sharp  razor, 
with  a  short  rapid  sawing  motion,  while  the  skin  is  held  taut.  The 
skin  and  the  razor  may  be  moistened  with  saline  solution,  to  facilitate 


j:;s  RECONSTRUCTIVE  SURGERY 

the  process.  The  long  grafts  arc  then  at  once  transfer  red  to  the 
granulating  surface,  previously  prepared,  and  spread  in  place,  covering 
nearly  its  entire  area  (Fig.  191).  Dressing  is  similar  to  that  for  the 
Reverdin  method. 


Fig.  191. — Eight  days  after  Thiersch  grafts  (from  father)  were  applied  to  abdomen  and 
groin.     The  white  areas  are  the  grafts.     Episcopal  Hospital. 

Thiersch  grafts  are  more  difficult  to  cut,  require  a  general  anesthetic, 
and  are  less  apt  to  grow  than  the  smaller  grafts  of  Reverdin;  but  if 
they  do  grow,  the  healing  of  the  ulcer  is  very  much  more  rapid  and  the 
resulting  scar  less  conspicuous. 


Fig.   192. — Epithelioma  of  temple.     See  Fig.  193. — Same  patient  nine  days  after 

Fig.  193.     Episcopal  Hospital.  excision  of  epithelioma  and  implantation 

of  Wolfe  graft.     Episcopal  Hospital. 

Wolfe-Krause  Method. — The  entire  thickness  of  the  skin  is  trans- 
planted,  but  without  any  subcutaneous  tissue.     The  graft   is    dis- 


SKIN-GRAFTING 


239 


sected  free  by  an  extremely  sharp  scalpel,  and  is  sutured  in  the  defect, 
being  closely  applied  throughout  its  extent  to  the  underlying  tissue 
(Figs.  192  and  193).  The  entire  operation  should  be  dry  and  abso- 
lutely aseptic.  The  graft  is  dressed  as  in  other  methods,  and  should 
be  kept  constantly  warm  by  hot  water  bottles.  This  is  the  best 
method  to  fill  in  a  recently  made  wound,  provided  this  may  be  com- 
pletely filled  by  a  single  graft;  one  with  a  diameter  of  more  than  7 
cm.  is  not  apt  to  prove  successful.     For  granulating  surfaces  Boykin's 


Fig.  194. 


-Small  deep  grafts  ten  days  after  application  to  granulating  area  resulting 
from  excision  of  a  carbuncle.     Episcopal  Hospital. 


method  (1916)  of  Wolfe  grafting  is  preferable;  here  numerous  grafts 
are  cut  in  the  same  manner  as  described  for  Reverdin's  grafts,  but 
each  is  from  1  to  2  cm.  in  diameter,  and  includes  the  entire  thickness 
of  the  skin.  They  are  placed  not  more  than  1.5  cm.  distant  from  each 
other,  and  are  dressed  as  already  described,  being  kept  warm  for  about 
a  week  by  hot  water  bags.  Figs.  194  and  195  are  from  a  patient  in 
my  service  on  whom  Dr.  Boykin  operated.  The  operation  may  be 
done  under  local  anesthesia. 


240 


RECONSTRUCTIVE  SURGERY 


Fig.  195. — The  same  patient  twenty-seven  days  after  skin  grafting.     Episcopal  Hospital. 


PLASTIC    SURGERY. 

The  form  of  plastic  surgery  most  often  employed  is  that  by  transfer 
of  flaps  from  the  immediate  neighborhood.  The  simpler  the  opera- 
tion, the  more  successful  it  is  likely  to  be;  hence  the  simpler  methods 
always  should  be  tried  first,  unless  manifestly  inadequate.  Even 
such  operations  will  not  succeed  unless  infection  is  absent,  and  unless 
no  active  disease  exists  in  the  parts  on  which  the  operation  is  done. 
Lupus  and  syphilitic  ulcerations  must  be  healed,  and  the  disintegrat- 
ing process  at  a  standstill  before  any  plastic  surgery  is  attempted. 
Another  maxim  of  extreme  importance  in  plastic  surgery  is  to  do  too 
little  rather  than  too  much  at  each  stage  of  the  operation,  which  is 
often  thus  better  divided  into  several  sittings.  Cicatricial  tissue 
usually  should  be  excised  and  not  employed  in  plastic  surgery  as  it  is 
very  apt  to  slough.  This  applies  more  particularly  to  the  subcu- 
taneous tissues,  cicatricial  skin  acting  very  well  when  freed  from  the 
underlying  scars. 

When  a  defect  already  exists  or  is  made  by  excision  at  the  time  of 
operation,  it  usually  is  in  one  of  the  forms  shown  in  the  annexed  dia- 


PLASTIC  SURGERY 


241 


grams  (Fig.  196);  and  the  various  methods  currently  employed  for 
closing  such  gaps  are  indicated.  The  special  method  chosen  depends 
on  the  tissues  available. 


«%  f    f   f  ¥- 


Y    y    ytk^y    y    f 


Fig.  196. — Typical  plastic  operations. 

In  all  plastic  operations  great  gentleness  should  be  used  in  manipu- 
lation; strict  hemostasis  by  the  finest  catgut  ligatures  must  be  secured, 
and  accurate,  but  not  too  tight  approximation  must  be  obtained. 

16 


242 


RECONS TR UC TI VE  S URGER Y 


Relaxation  sutures  (p.  104)  often  are  essential.  The  flaps  should 
contain  a  moderate  amount  of  subeutaneous  tissue,  and  their  bases 
should  be  broad  and  should  contain  the  main  vascular  supply;  and  the 
Haps  should  be  made  of  sufficient  size  to  allow  for  inevitable  shrink- 
age, especially  when  cut  from  tissues  naturally  lax  (neck,  scrotum), 
as  in  them  retraction  is  greatest.  If  the  base  of  the  flap  is  much 
twisted  in  adjustment,  it  must  be  divided  (to  restore  contour)  in 
from  two  to  three  weeks  after  the  first  stage  of  the  operation. 


Fig.  197. — Ulcers  resulting  from  exten- 
sive burns  received  three  months  pre- 
viously.    Episcopal  Hospital. 


Fig.  198. — Same  patient,  two  months 
later,  after  complete  cicatrization.  Epis- 
copal Hospital. 


When  a  fold  of  cicatricial  tissue  exists,  as  in  the  axilla  or  elbow, 
what  is  known  as  Z-plasty  is  very  satisfactory :  the  tense  edge  of  the 
flap  is  split,  and  from  each  end  of  this  first  incision  is  carried  another 
diverging  at  an  acute  angle  on  opposite  sides  of  the  web;  the  entire 
incision  is  thus  Z-shaped.  The  two  triangles  thus  outlined  are  dis- 
sected up,  the  subcutaneous  scar  tissue  is  excised,  and  the  joint  fully 
extended,  when  two  lax  triangular  flaps  will  be  available  for  covering 
the  flexure  of  the  joint,  the  upper  triangle  filling  the  distal  portion 
of  the  defect,  and  the  lower  triangle  the  proximal  portion  (Figs.  197 
to  205).  In  this  way  the  only  cicatrix  left  in  the  flexure  of  the  joint 
runs  transversely  and  cannot  reform  a  web. 

When  a  flap  is  to  be  transferred  from  a  distance,  a  site  of  the  body 


PLASTIC  SURGERY 


243 


must  be  selected  which  can  be  easily  brought  into  contact  with  the 
affected  region;  and  the  skin  to  be  transplanted  should  resemble  as 
closely  as  possible  that  of  the  part  to  which  it  is  to  be  transferred. 
In  defects  of  the  back  of  the  hand  a  pocket  may  be  made  in  the  oppo- 
site side  of  the  chest,  to  which  the  hand  is  sutured  for  a  couple  of 
weeks.  For  the  palm  of  the  hand  the  buttock  of  the  same  side  has 
been  employed,  but  the  skin  is  too  dissimilar  to  give  a  good  cosmetic 
result.     A  flap  from  one  shin  may  be  easily  attached  to  the  other. 


Fig.  199. — Same  patient  as  Fig.  197, 
one  year  later,  after  extensive  plastic 
operations.     Episcopal  Hospital. 


Fig.  200. — Same  patient  one  year  after 
complete  cicatrization,  showing  result  of 
extensive  plastic  operations.  Episcopal 
Hospital. 


Gillies  (1918)  has  developed  a  method  of  transplants  with  tubular 
pedicles,  by  which  skin  areas  from  a  considerable  distance  may  be 
successfully  transplanted.  A  large  area  of  the  skin  of  the  forehead  or 
neck  or  chest,  attached  at  each  side  by  long  pedicles  (the  free  margins 
of  which  are  sutured  to  each  other,  converting  each  pedicle  into  a 
tube,  thus  ensuring  better  nutrition)  may  by  this  means  be  used  to 
restore  defects  of  the  face;  after  the  parts  have  united,  the  tubular 
pedicles  are  detached  from  the  face,  and  the  tubes  are  unfolded  and 
restored  to  their  original  situation. 

The  method  of  transferring  a  flap  by  successive  migrations  is  very 
seldom  employed. 

Unhealed  cavities  following  operations  for  osteomyelitis,  empyema, 


211 


RECONSTRUCTIVE  SURGERY 


Fig.  201. — Fingers  amputated  and 
t  luunl)  useless  from  contractures,  as  result 
of  injury  by  hand  grenade.  Walter 
Reed  General  Hospital. 


Fig.  202. — Same  patient  as  Fig.  201, 
one  month  after  Z-plasty  for  web  of 
thumb.  Can  now  oppose  thumb  to  stumps 
of  fingers.    Walter  Reed  General  Hospital. 


Fig.  203. — Incurvation  of  the  penis  from  congenital  shortness  of  frsenum. 
Episcopal  Hospital. 


Fig.  204. — Diagram  of  Z-plasty  for 
shortened  frsenum. 


Fig.  205. — Method  of  suture  of 
the  flaps  outlined  in  Fig.  204,  restor- 
ing meatus  to  norma'  site  at  apex  of 

glans. 


FREE  TRANSPLANTS 


245 


etc.,  may  be  covered  in  by  skin  flaps,  derived  from  the  immediate 
neighborhood  or  transferred  from  a  distance.  E.  G.  Beck  (1918)  has 
recently  done  much  work  of  this  kino!. 

Compound  Flaps,  containing  fat,  fascia,  muscle  or  even  bone,  are 
occasionally  used,  the  pedicle  consisting  only  of  skin  and  subcutaneous 
tissues.  Or  a  flap  may  be  used  having  only  an  island  of  skin  on  its 
surface,  the  pedicle  consisting  of  subcutaneous  tissue  only,  as  in 
cases  reported  by  Monks  (1898)  and  Horsley  (1915)  in  which  defects 
of  the  face  were  repaired  by  the  transfer  of  an  island  of  skin  from  the 
temple,  containing  the  temporal  artery  in  the  pedicle. 


Fig.  206. — Transplantation  of  the  pectoralis  maior  muscle  to  supplant  the  deltoid.  The 
origin  of  the  muscle  is  detached  from  the  clavicle  and  upper  ribs,  and  with  nerve  supply 
intact  is  re-attached  to  the  acromion  and  outer  end  of  the  clavicle.  This  boy  was  unable 
to  execute  the  movement  of  propulsion  of  the  shoulder  before  operation,  but  regained 
it  after  operation.     Episcopal  Hospital. 

Transfer  of  Muscles. — Muscles  may  have  their  origins  shifted,  so 
as  to  substitute  other  muscles  which  have  been  paralyzed  or  destroyed 
by  injury.  It  has  been  shown  that  a  muscle  may  be  almost  severed 
from  its  blood  supply,  yet  retain  its  functions  so  long  as  its  nerve 
supply  is  intact.  Thus  the  origin  of  the  pectoralis  major  may  be 
divided,  and  the  muscle  may  be  shifted  so  as  partially  to  supplant 
the  deltoid  (Fig.  206)  (Hildebrand,  1905). 


FREE    TRANSPLANTS. 

Argument  still  continues  among  experimental  surgeons  as  to  whether 
a  free  transplant,  especially  of  bone,  continues  to  live  as  an  entity 
in  its  new  site,  or  whether  it  becomes  disintegrated  and  is  replaced 
by  permeation  of  surrounding  tissues.  It  is  fairly  certain  that  free 
transplants  of  skin  (skin-grafts)  continue  their  individual  existence, 
and  not  improbable  that  transplants  of  fat,  fascia,  tendon  and  carti- 


24f>  RECONSTRUCTIVE  SURGERY 

lage  do;  and  while  it  is  improbable  that  an  entire  transplant  of  bone, 
unless  very  minute,  continues  to  live  as  a  whole,  it  is  highly  probable 
if  not  certain  that  portions  of  it  live,  and  that  for  this  reason  it  is 
better  tolerated  than  foreign  substances.  Therefore  an  auto-trans- 
plant, even  of  bone,  is  preferable  to  a  homotransplant,  and  still  more 
so  to  the  use  of  silk  for  ligaments  or  tendons,  of  animal  membranes  for 
fascia,  of  silver  or  celluloid  plates  for  cartilage  or  bone  in  skull  defects, 
or  to  that  of  ivory  pegs  or  ox-bone  inlays  in  the  long  bones. 

In  all  operations  involving  free  transplantation  of  tissue,  asepsis 
(better  than  antisepsis)  and  strict  hemostasis  are  necessary.  The 
transplants  should  not  be  cut  until  their  bed  has  been  prepared, 
and  when  cut,  should  be  transferred  without  unnecessary  delay.  In 
all  except  bone  and  some  cartilage  transplants,  which  usually  may 
be  wedged  into  position,  or  retained  by  suturing  an  overlying  layer  of 
fascia,  it  is  well  to  fix  the  transplant  in  place  with  buried  catgut 
sutures.     No  drainage  should  be  employed. 

Fat. — Fat  is  admirably  adapted  for  transplantation;  it  is  obtained 
from  the  buttocks  when  coarse  fat  is  desired,  or  from  the  flexor  sur- 
faces of  the  upper  limb  or  from  around  the  tendon  of  Achilles  when 
fat  of  finer  texture  is  needed.  The  former  serves  merely  to  fill  in 
hollows  for  cosmetic  purposes,  while  the  finer  texture  is  better  for 
preventing  injurious  adhesions.  For  the  latter  purpose  it  has  largely 
superseded  the  use  of  Cargile  membrane.  Transplants  of  fat  should 
be  cut  about  one-third  larger  than  the  size  actually  needed,  as  they 
shrink  when  cut,  and  may  grow  smaller  during  the  process  of  repair. 
A  slight  discharge  of  disintegrated  fat,  which  sometimes  occurs  between 
the  sutures  does  not  necessarily  mean  than  the  entire  transplant  is 
sloughing;  and  even  when  a  considerable  amount  is  discharged  the 
result  may  be  satisfactory. 

Tendons.- — Transfer  of  the  insertion  of  tendons,  the  tendons  them- 
selves remaining  attached  to  their  respective  muscles,  is  discussed 
sufficiently  in  connection  w7ith  infantile  paralysis  (p.  568).  Here 
attention  is  called  to  the  substitution  of  tendons  destroyed  by  slough- 
ing or  otherwise  by  the  total  transplantation  of  portions  of  other 
tendons.  For  instance  the  tendon  of  the  palmaris  longus,  which  is 
not  of  much  use,  has  been  excised  and  inserted  in  the  finger,  being 
sutured  at  the  proximal  end  to  the  stump  of  the  lost  tendon  in  the 
palm,  and  at  the  distal  end  attached  to  bone.  As  it  is  difficult  to 
construct  vincula  to  hold  the  tendon  in  contact  with  the  phalanges, 
Lexer  (1914)  adopted  the  expedient  of  having  the  patient  wear  a  ring 
on  the  affected  finger,  which  prevents  the  new  tendon  from  pulling 
aw>ay  from  the  phalanges  during  attempts  at  flexion. 

Fascia. — Fascia,  usually  obtained  from  the  fascia  lata,  may  be  used 
for  many  purposes:  (1)  Cut  into  strips  and  doubled,  it  becomes 
strong  enough  to  act  as  a  tendon  or  ligament.  (2)  Rolled  into  a  tube 
it  has  been  used  to  surround  nerve  and  tendon  anastomoses  in  the 
expectation  (which  has  not  always  been  fulfilled)  that  its  presence  would 
prevent  development  of  injurious  adhesions;  its  use  for  this  purpose 


FREE  TRANSPLANTS 


247 


has  been  abandoned  by  many  surgeons,  who  find  free  transplants  of 
fat  more  satisfactory.  (3)  As  an  insertion  after  an  economical  resec- 
tion of  joints,  to  prevent  reunion;  it  is  questionable  whether  this  is 
as  apt  to  be  successful  as  the  use  of  pedunculated  flaps  (see  Arthro- 
plasty, p.  252).  (4)  As  an  insertion  between  the  skin  and  brain,  to 
replace  the  dura  in  cases  of  adherent  cicatrices,  in  an  effort  to  obviate 
symptoms  considered  due  to  the  superficial  scar. 


Fig.  207. — Dental  engine  and  circular  saw  used  in  operations  for  bone  transplantation. 

Orthopaedic  Hospital. 


Cartilage. — Cartilage,  usually  costal  in  origin  (sixth  to  eighth  ribs), 
has  been  used  to  form  a  bridge  for  the  nose,  to  fill  defects  in  the  skull, 
to  bridge  gaps  in  the  mandible,  etc  About  two-thirds  of  the  thickness 
of  the  costal  cartilage  is  included  in  the  transplant.  It  has  the  advan- 
tage over  bone  that  it  is  more  easily  cut  and  shaped,  and  that  it 
appears  to  endure  indefinitely  in  its  new  site  as  cartilage  even  when 
not  attached  to  other  cartilage  or  bone  (J.  Staige  Davis,  1917).     When 


248 


RE(  'ONSTRUCTIVE  SI ' RGERY 


used  for  filling  a  skull  defect  too  large  to  be  covered  by  one  piece,  the 
cartilage  is  applied  in  strips,  each  of  which  must  be  in  contact  with 
the  freshened  skull  edges  at  both  ends.  "Since  the  grafts  take  on  a 
pounded  shape  with  the  convexity  toward  the  cut  surface,  the  smooth 
perichondria!  side  is  placed  next  the  brain"  (Wilson,  L919). 

Bone.—  Bone  is  the  most  widely 
used  of  all  free  transplants,  the 
usual  source  being  the  subcuta- 
neous surface  of  the  tibia.  Its  main 
uses  arc: 

1.  For  defects  of  the  long  bones, 
due  to  their  congenital  absence  or 
to  their  operative  removal  (Figs. 
208  to  213). 


Fig.  208. — Six  weeks  after  excision  of 
metacarpal  shaft  for  necrosis  following 
lacerated  wound  from  human  teeth. 
Episcopal  Hospital. 


Fig.  209. — Same  patient  as  in  Fig.  208, 
three  weeks  after  bone  transplantation. 
Normal  length  of  finger,  restored.  Epis- 
copal Hospital. 


2.  For  ununited  fractures,  thetransplant  bridging  the  gap,  large 
or  small,  and  acting  as  an  osteoinductive  tract  promoting  bonv  union 
(p.  354).  _ 

3.  For  immobilization  of  the  spine  in  eases  of  tuberculosis,  according 
to  Albee's  method  (p.  659). 

For  the  operation  of  transplanting  bone  the  use  of  a  motor-driven 
circular  saw  is  almost  indispensable.  Many  types  are  on  the  market, 
that  of  Albee  being  most  popular;  in  this,  as  in  certain  other  types, 
the  motor  is  held  in  the  hands,  and  the  saw  is  attached  directly  to  a 
short  shaft.     Personally  I  have  always  employed  a   dental    engine, 


FREE  TRANSPLANTS 


249 


which  obviates  the  necessity  of  holding  the  heavy  motor  in  the  hands, 
as  the  power  is  transmitted  by  a  cord  and  pulleys  to  a  light  shaft 
which  is  readily  controlled  by  the  surgeon  (Fig.  207).  In  cutting- 
slots  for  the  reception  of  a  transplant,  as  well  as  in  outlining  the 
transplant  itself,  a  twin  circular  saw  is  a  convenience  but  not  a  neces- 
sity. The  surgeon  first  prepares  the  site  which  is  to  receive  the  bone. 
If  the  transplant  is  to  be  used  to  span  a  gap  in  a  long  bone,  it  may 
be  placed  as  an  inlay  in  slots  cut  in  each  fragment  to  receive  it,  or 
as  is  less  often  done,  it  mav  be  driven  into  the  medullary  canal  of 


Fig.  210. — Myeloma  of  radius  before  operation.     Duration  one  year. 
See  Figs.  63  and  211.     Orthopaedic  Hospital. 


each  fragment  as  a  peg.  Usually  when  the  latter  plan  is  adopted 
the  medulla  must  be  reamed  out  to  receive  the  bone  peg.  In  opera- 
tion for  ununited  fracture  of  the  hip,  it  is  convenient  to  ream  out  a 
hole  through  the  neck  and  head  from  the  outer  surface  of  the  femur 
below  the  trochanter  (Fig.  343).  If  the  defect  is  not  very  great  it  may 
be  possible  to  cut  the  transplant  from  another  portion  of  the  same  bone, 
as  in  Buchanan's  original  method  (1912),  which  Albee  terms  the 
sliding  inlay  (Fig.  340).  If  it  is  considered  important  to  have  the 
transplant  as  large  as  the  bone  to  which  it  is  to  become  attached,  it 


2")0 


RECONSTRUCTIVE  SURGERY 


may  be  fastened  end-to-end  by  a  steel  plate  (Fig.  211),  or  it  may  be 
mortised  into  the  medulla  of  the  receiving  bone 

In  cutting  the  transplant  the  periosteum  usually  is  left  attached, 
so  far  as  possible.  I  believe  this  is  of  value  only  when  the  transplant 
is  not  to  be  embedded  in  bone;  if  it  is  used  as  an  intramedullary  peg, 
or  if  buried  in  bone  as  when  inserted  in  the  spinous  processes  of  the 
vertebra?  in  cases  of  Pott's  disease  (p.  059),  retention  of  the  perios- 
teum is  a  detriment,  hindering  rather  than  promoting  permeation 
of  the  transplant   by  the   surrounding  bone  cells.     If,  however,  the 

transplant  is  to  span  a  gap  (Figs.  211  and 
212),  and  is  exposed  to  the  action  of  for- 
eign connective-tissue  cells,  it  is  well  to 
leave  the  periosteum  intact,  to  act  as  a 
limiting  membrane  and  protect  the  trans- 
planted bone  from  absorption.  There  is 
much  contradictory  experimental  evidence 
on  the  role  of  the  periosteum  in  bone 
growth,  but  from  clinical  experience  the 
advice  above  seems  to  be  just.1  After  trans- 
plantation, bone  will  become  hypertrophied 
to  meet  the  requirements  of  its  new  duties; 
disuse  causes  it  to  atrophy. 

In  removing  bone  from  the  tibia,  the 
subcutaneous  surface  is  exposed  by  a  curved 
incision,  turning  aside  a  flap  so  that  the 
skin  scar  will  not  fall  directly  over  the 
bone  defect.  The  transplant  is  cut  from 
the  antero-internal  face  of  the  tibia,  leaving 
the  crest  intact,  as  on  this  the  strength  of 
the  tibia  largely  depends,  and  fractures 
have  occurred  in  some  cases  during  con- 
valescence where  it  has  been  sacrificed.  If 
the  saw  is  made  to  sink  at  once  into  the 
medulla,  enough  bleeding  will  occur  to 
keep  the  bone  moist,  and  there  will  be 
little  danger  of  the  heat  generated  by  the 
saw  injuring  the  bone.  The  transplant 
being  outlined  by  the  saw,  is  raised  from 
its  bed  by  osteotome  or  chisel,  and  at  once 
transferred  to  its  new  site.  During  any  delay  it  should  be  wrapped 
in  dry  sterile  gauze;  putting  it  into  saline  solution  may  wash  away 
some  of  the  bone  cells.     Both  wounds  are  closed  without  drainage, 

1  Oilier  (1867)  taught  that  periosteum  was  the  chief  factor  in  new  bone  forma- 
tion, especially  its  deep  or  cambium  layer.  Experiments  by  Axhausen  (1907-1911) 
and  others  supported  this  view.  Macewen  (1912)  held  the  theory  that  the  peri- 
osteum was  only  a  limiting  membrane,  and  that  bone  itself  was  chiefly  responsible 
for  its  own  reproduction.  But  as  Ely  (1919)  very  justly  points  out  periosteum 
and  its  cells  extend  into  the  cortex  (Sharpey's  fibers)  while  marrow  cells  may 
exist  in  the  periosteum. 


Fig.  211. — Same  case  as  Figs. 
63  and  210  after  bone  trans- 
plant. Excellent  function  and 
no  recurrence  after  five  years. 


FREE  TRANSPLAXTS 


251 


and  the  parts  properly  immobilized  until  union  occurs,  usually  in 
the  course  of  ten  or  twelve  weeks.  If  the  transplant  must  bear 
much  weight  (leg,  thigh,  spine),  suitable  apparatus  should  be  worn 
for  a  number  of  months. 


Fig.  212. — Same  patient  as  in  Figs. 
68  and  69.  Spindle-cell  sarcoma  of 
periosteum  of  tibia,  seven  months  after 
excision  of  tibia  and  implantation  of 
fibula  and  transplant  from  other  tibia 
(20  cm.  long)  into  condyles  of  femur. 
Episcopal  Hospital. 


Fig.  213. — Side  new  of  leg  shown  in  Fig. 
212.  The  fibula  has  slipped  from  its  socket 
in  the  external  condyle,  but  the  tibial  trans- 
plant remains  firm.  Useful  leg  with  nearly 
stiff  knee.  No  recurrence  three  and  one- 
half  years  later. 


Transplantation  of  Entire  Bone  Ends,  with  cartilage  and  ligaments 
attached  has  been  done  by  Lexer  (1908)  and  others,  from  amputated 
limbs  or  cadavers,  implanting  them  into  the  space  left  by  excision  of 
the  diseased  bone  (chiefly  tibia  or  femur  at  knee).  Though  fair 
function  was  obtained  at  least  for  a  time  in  some  cases,  one  patient 


252  R /••''  VNS TR rem 7<:  S I ' RGE R Y 

became  melancholy  from  the  consideration  of  the  fact  that  he  was 
host  to  a  dead  man's  knee,  and  subsequently  demanded  to  have  his 
thigh  amputated. 

Transplantation  of  Entire  Bones,  as  the  astragalus  to  form  a  new 
head  for  the  femur  (Roberts,  1912),  has  also  been  practised  in  a  few 
cases. 

ARTHROPLASTY. 

This  is  an  operation  designed  to  substitute  a  joint  which  is  stiff  by 
one  which  is  movable  but  stable,  with  the  minimum  amount  of  bone 
resection,  by  interposition  between  the  bone  ends  of  pedicled  flaps 
of  fat,  fascia  or  muscle.  Free  transplants  of  fascia  lata  may  be  used 
when  flaps  cannot  be  obtained  from  the  neighborhood.  But  it  seems 
advantageous  to  have  the  flaps  thicker  than  fascia  alone.  Baer 
(1909)  uses  a  prepared  animal  membrane  (pig's  bladder).  Murphy 
(1904)  did  much  to  systematize  the  technique.  It  may  prove  a  difficult 
operation,  requires  special  training  and  experience  in  joint  surgery, 
and  is  not  always  successful.  At  the  shoulder  and  elbow-joints  it  is 
not  much  preferable  to  typical  excision,  since  great  stability  is  not 
required;  at  the  hip  and  knee  where  stability  is  important,  the  result 
of  an  arthroplasty  may  be  more  disabling  than  an  absolutely  stiff  joint. 
At  the  wrist  and  ankle  it  has  seldom  been  employed.  In  exceptional 
cases  it  is  of  utility  in  the  finger-joints,  though  many  patients  will 
prefer  amputation.  But  in  any  strong  and  healthy  patient  its  merits 
deserve  serious  consideration,  especially  in  those  with  ankylosis 
in  bad  position,  or  with  more  than  one  joint  ankylosed  (Fig.  221). 
Its  best  field  is  in  cases  of  bony  ankylosis  following  metastatic  arth- 
ritis (p.  515)  where  little  bone  destruction  has  occurred,  since  in  these 
the  original  form  of  the  joint  may  be  largely  restored.  Its  use  in 
cases  of  tuberculous  ankylosis,  which  is  never  very  firm  (unless  at  the 
knee,  following  excision),  is  not  yet  on  a  solid  foundation;  and  in  my 
opinion  is  not  to  be  recommended.  Nor  should  it  be  employed  in  any 
other  case  where  the  disease  is  still  active  or  has  only  recently  become 
quiescent.  A  period  of  several  months  at  least  should  elapse  after 
a  bacterial  infection  of  the  joint,  and  if  the  infection  is  known  to  have 
been  streptococcic  (as  in  a  case  of  gunshot  fracture)  a  longer  period 
still  is  required.  Nor  is  the  operation  suitable  for  cases  of  fibrous 
ankylosis  seen  in  joint  dystrophies. 

In  performing  the  operation,  exposure  of  the  joint  should  be  free, 
important  ligaments  should  be  preserved,  and  the  flaps  (of  ample  size) 
should  have  their  pedicles  close  to  the  joint  and  of  sufficient  thickness 
to  ensure  their  vitality.  It  is  best,  when  possible,  to  complete  the 
resection  of  the  bones  before  cutting  the  flaps.  The  latter  are  attached 
by  catgut  sutures  in  their  new  situation,  and  what  remains  of  the 
joint  capsule  is  sutured  around  them.  Hemostasis  should  be  com- 
plete, and  no  drainage  should  be  used.  The  limb  is  put  up  in  the 
most  stable  position,  with  sufficient  traction  to  prevent  pressure  on 
the  flaps,  and  the  joint  is  kept  quiet  until  the  soft  parts  have  healed, 


ARTHROPLASTY 


253 


when  active  motion  is  encouraged,  and  passive  movements,  within 
the  range  of  painlessness,  are  daily  employed.  Long  and  persistent 
after-treatment  with  gymnastics,  massage,  etc.,  usually  is  necessary 
to  secure  the  full  benefit  from  the  operation. 

Arthroplasty  of  Temporo-mandibular  Joint. — See  p.  709. 

Arthroplasty  of  the  Shoulder. — The  joint  is  exposed  by  a  curved 
incision  around  the  acromion  from  coracoid  process  to  the  spine 
of  the  scapula  (Senn,  1901);  the  acromion  is  cut  through  at  its  base 
with  osteotome  (Kocher,  1894),  guarding  the  suprascapular  artery 
and  nerve  (Fig.  214);  the  acromion  with  attached  deltoid  is  then 
turned  down  exposing  the  shoulder-joint  which  is  economically  resected, 
by  gouge  and  gouge  forceps,  until  free  motion  is  secured.  A  flap  of 
fascia  and  muscle  is  then  detached  from  the  deep  surface  of  the  del- 
toid, from  the  coracobrachialis  or  short  head  of  the  biceps,  or  even 
from  the  pectoralis  minor.  The  arm  is  put  up  in  abduction  and  slight 
external  rotation. 


Fig.  214. — Arthroplasty  of  the  Shoulder.     Spine  of  scapula  exposed  and  retractor 
passed  under  base  of  acromion. 

Arthroplasty  of  the  Elbow. — An  incision  along  the  external  supra-con- 
dylar  ridge  exposes  the  external  condyle,  which  is  detached,  and  turned 
down  (Fig.  215),  carrying  with  it  the  external  lateral  ligament  and  origin 
of  the  supinator  and  extensor  muscles.  The  union  between  ulna 
and  humerus  having  been  divided,  the  forearm  is  strongly  adducted 
around  the  internal  lateral  ligament  as  a  hinge,  thoroughly  expos- 
ing the  bone  ends  (Fig.  216);  these  are  then  shaped,  enough  bone 
being  removed  to  leave  at  least  2  cm.  interval  when  the  elbow  is 
extended  under  moderate  traction.  A  flap  is  then  cut  from  the 
dorsal  surface  of  the  triceps,  with  pedicle  near  the  olecranon,  is  turned 
across  the  humerus  and  is  stitched  in  place.  The  elbow  is  then 
reduced,  and  the  external  condyle  reattached  by  sutures  or  screw 
(Ashhurst,  1915). 

Arthroplasty  of  the  Wrist. — Through  a  long  dorsal  incision  between 
the  tendon  of  the  extensor  indicis  and  the  extensor  pollicis  longus, 
enough  bone  is  gouged  out  to  allow  very  free  motion,  and  a  free 
transplant  of  fat  or  fascia  lata  is  inserted. 


254 


UFA  'ONSTRUCTI  VE  SURGER  Y 


Arthroplasty  of  the  Fingers. — Lateral  incisions  should  be  used,  and 
free  fat  transplants  inserted  (Payr,  1914). 


Fig.  215. — Elbow  exposed  for  arthro- 
plasty. 


Fig.  216. — Joint  luxated  around  internal 
lateral  ligament  as  a  hinge. 


Arthroplasty  of  the  Hip. — A  curved  incision  passes  from  the  anterior 
superior  spine  of  the  ilium,  down  below  the  great  trochanter,  and  up 
posteriorly  in  the  direction  of  the  fibers  of  the  gluteus  maximus;  and 


Fig.  217. — Reaming  the  acetabulum  in  the  arthroplasty  of  the  hip. 

the  flap  thus  outlined,  including  the  facia  lata,  is  turned  upward. 
The  great  trochanter  is  cut  off  by  osteotome,  carrying  with  it  the 
attachment   of  the   gluteus  medius   (Oilier,    1879).     The  capsule  of 


ARTHROPLASTY 


255 


the  joint  is  incised  along  its  upper  border,  and  the  Y-ligament  is 
detached  from  the  anterior  intertrochanteric  line,  the  flap  of  capsule 
thus  made  being  turned  in  and  down.  With  large  gouge  the  femur 
is  cut  from  the  pelvis,  and  is  luxated  anteriorly  by  external  rotation 
and  adduction  of  the  limb,  exposing  the  acetabulum,  which  is  deep- 
ened with  gouge.  The  head  of  the  femur  and  its  socket  may  be 
rounded  off  with  Murphy's  end-mill  and  reamer  (Fig.  217).  A  flap  of 
fascia  lata  and  fat  is  then  dissected  off,  the  skin  flap  turned  up  at  the 
beginning  of  the  operation,  the  pedicle  of  the  fascia  being  well  pos- 
terior; the  flap  is  inserted  across  the  acetabulum,  and  properly  fixed 
by  sutures.  Next  the  head  of  the  femur  is  replaced  against  the  flap, 
and  the  capsule  sutured  over  it.  Then  the  great  trochanter,  with 
attached  gluteus  medius  is  brought  down,  anterior  to  the  pedicle  of 
the  fascia  flap,  and  is  held  in  place  with  sutures  or  screws.  Finally 
the  skin  flap  is  replaced,  and  weight  extension  (15  to  20  pounds) 
applied. 


Fig.  218  Fig.  219  Fig.  220 

Figs.  218,  219  and  220. — Result  of  arthroplasty  of  hip  for  bony  ankylosis. 

Orthopsedic  Hospital. 

Arthroplasty  of  the  Knee. — Two  long  lateral  incisions  (15  to  20  cm.) 
are  employed,  converging  below  in  the  region  of  the  tibial  tubercle, 
where  they  are  about  4  cm.  apart,  while  their  upper  ends  are  about 
10  or  12  cm.  apart.  Open  the  joint  on  each  side  of  the  patella,  chisel 
the  latter  free  from  the  femur,  and  remove  most  of  its  under  surface, 
leaving  little  more  than  its  anterior  fibrous  surface.  Then  divide 
the  femur  from  the  tibia,  luxating  the  patella  first  to  one  side  and  then 
to  the  other  until  the  knee  can  be  fully  flexed,  and  the  bone  ends 
properly  shaped.  Cut  an  intercondylar  groove  in  the  femur  both  on 
its  end  and  its  extensor  surface,  and  remodel  a  spine  on  the  end  of 
the  tibia.     Cut  one  long  flap  on  the  outer  side  from  the  fascia  lata 


256 


RK(  'OSSTRVCTl  VE  SURGERY 


and  muscle  above  the  external  condyle;  or  two  short   flaps,  one  from 
each  side  may  he  used.     Turn  the  flap  across  the  femoral  condyles 

and  attach  it  by  sutures.  Next  fold  around 
the  under  surface  of  the  patella  the  lateral 
expansions  of  the  quadriceps  tendon  and 
attach  them  to  each  other  by  sutures  (G. 
(i.  Davis),  or  if  the  extensor  apparatus  is 
too  long,  owing  to  excision  of  the  joint, 
the  patella  may  be  rotated  on  its  long  axis, 
bringing  the  upper  surface  of  the  patella 
against  the  condyles  (Murphy).  The  soft 
parts  are  then  closed  and  weight  extension 
(10  to  15  pounds)  applied. 

Arthroplasty  of  the  Ankle. — Make  an  ante- 
rior transverse  incision  through  the  skin, 
passing  between  the  anterior  tibial  artery 
and  the  tendon  of  the  extensor  longus  hallu- 
cis  to  expose  the  joint.  After  this  has  been 
excised,  insert  a  free  transplant  of  fat  and 
fascia  lata. 


Fig.  221. — Bony  ankylosis  of 
elbow  and  knee.  Orthopaedic 
Hospital. 


CINEMATOPLASTIC    AMPUTATIONS. 

Vanghetti  (1906),  Ceci  and  other  surgeons 
have   devised    and   practised    methods    of 


Fig.  222. — Result  of  arthroplasties  of  elbow    Fig.  223. — Same  patient,  showing  nor- 
and  knee,  showing  limits  of  flexion.  mal  extension  of  elbow  and  knee. 


CINEMATOPLASTIC  AMPUTATIONS 


257 


amputating  which  provide  for  voluntary  motion  in  the  prosthesis. 
It  is  of  no  value  in  the  lower  extremity,  and  unless  some  satisfactory 
prosthesis  can  be  invented  will  prove  useless  in  the  upper  limb  in 
the  future  as  it  has  in  the  past. 

In  cases  of  recent  accidents  the  limb  is  amputated  in  the  ordinary 
manner,1  and  when  the  patient  has  recovered  his  normal  health  the 
stump  is  reopened,  and  the  flexor  and  extensor  muscles  are  sutured 
to  each  other  in  the  form  of  a  loop,  over  the  end  of  the  bone,  which 
is  resected  if  too  long;  the  loop  so  formed  is  covered  on  all  sides  by 
flaps  of  skin.  When  healing  is  complete,  a  stout  cord  is  passed  through 
this  tendinous  loop,  and  each  end  of  the  cord  is  attached  to  the  mech- 
anism of  the  prosthesis.  The  patient  can  then,  by  drawing  on  this 
loop,  flex  the  fingers  of  his  artificial  hand,  which  may  be  opened 
again  by  action  of  a  spring.  I  have  adopted  this  method  in  some 
cases,  but  so  far  have  not  found  any  manufacturer  in  this  country 
who  will  furnish  the  desired  cinematic  prosthesis  (Figs.  224  and  225). 


Fig.  224.  ■ —  Cinematoplastic 
amputation;  five  months  after 
operation.    Episcopal  Hospital. 


Fig.  225. — Cinematoplastic  amputation;  temporary 
prosthesis.     Episcopal  Hospital. 


Another  method,  practised  by  Francesco  (1908),  is  to  detach  the 
end  of  the  bone  from  its  diaphysis,  still  leaving  it  buried  in  the  muscu- 
lar mass  at  the  end  of  the  stump.  When  healing  is  complete,  a  ring 
of  iron  is  applied  around  the  stump  between  the  knob  of  bone  and  the 
diaphysis  from  which  it  has  been  detached.  As  this  detached  knob 
of  bone  is  voluntarily  movable,  the  ring  above  it  can  be  inclined  in 
any  direction,  and  through  attached  cords  transmits  the  movements 
to  the  prosthesis. 

In  amputations  of  the  forearm,  where  free  rotation  is  preserved,  it 
has  been  proposed  to  attach  a  ring  to  the  surface  of  the  stump,  and 


1  The   guillotine   amputation   (p.    217)   has  the    advantage   of    preserving  the 
greatest  length  of  limb  if  a  reamputation  is  contemplated. 
17 


258  RECONSTRUCTIVE  SURGERY 

connect  it  to  the  mechanism  of  the  Hand,  so  that  supination  move- 
ments might  close  the  fingers  and  pronation  open  them. 

In  Germany,  according  to  Primer  (1918),  a  modification  of  Yang- 
hetti's  procedure,  which  was  introduced  by  Sauerbruch,  has  been 
used  almost  to  the  exclusion  of  the  original  Vanghetti  method.  In 
this  a  tunnel  is  constructed  merely  in  a  muscle  belly  near  the  end 
of  the  stnmp,  and  to  the  rod  passed  through  this  tunnel  the  cords 
moving  the  hand  are  attached.  The  patients  seen  by  Druner  were 
not  satisfied  with  their  prostheses  and  proposed  to  abandon  them  as 
soon  as  discharged  from  the  hospital.  Moreover,  the  tunnels  through 
the  muscle  remained  tender  and  irritable. 


CHAPTER   X. 
SURGERY  OF  THE  BLOOD  VASCULAR  SYSTEM. 

Hemorrhage. — This  is  the  natural  consequence  of  injuries  which 
sever  the  walls  of  bloodvessels.  Hemorrhage  may  be  apparent, 
when  it  occurs  in  an  open  wound;  or  concealed  {internal),  when  it 
takes  place  into  one  of  the  natural  cavities  of  the  body.  Subcutaneous 
hemorrhage,  attended  by  extravasation  or  formation  of  a  hematoma, 
has  been  mentioned  at  p.  160. 

The  signs  of  hemorrhage  are  both  local  and  constitutional.  The 
local  signs  of  venous  and  arterial  hemorrhage  are  different,  but  the 
constitutional  signs  are  identical.  Venous  hemorrhage  is  characterized 
by  the  darker,  bluish  color  of  the  blood;  by  its  flowing  in  a  steady 
stream,  not  in  spurts;  and  in  most  cases  of  wounds  of  the  extremities 
by  the  ease  with  which  it  is  arrested  simply  by  elevation  of  the  part. 
Arterial  hemorrhage  occurs  in  rhythmic  jets,  and  the  blood  usually 
is  of  a  distinctly  redder  tinge. 

Constitutional  Signs  of  Hemorrhage. — As  the  volume  of  blood  within 
the  vascular  channels  is  rapidly  lessened  by  hemorrhage,  the  heart 
begins  automatically  to  pulsate  more  quickly.  A  steady  rise  in  the 
pulse  rate  is  one  of  the  surest  signs  of  hemorrhage.  As  the  quantity 
of  blood  in  the  system  decreases,  faintness  comes  on:  there  is  thirst, 
rapid  and  sighing  respiration  {air-hunger) ;  the  skin  becomes  blanched 
and  clammy;  the  lips  and  conjunctivae  are  pale;  the  ears  ring;  vision 
fails;  specks  and  blackness  float  before  the  eyes;  restlessness  and 
delirium  come  on;  involuntary  dejections  may  occur;  and  with  one 
or  two  gasps  the  patient  may  seem  dead.  At  this  stage  bleeding 
may  cease  spontaneously,  owing  to  the  diminished  force  of  the  circula- 
tion which  permits  thrombosis;  but  it  may  begin  again  when  reaction 
sets  in.  After  very  severe  or  repeated  hemorrhages,  faintness  is 
prone  to  recur;  and  the  patient  may  be  feverish  and  delirious  for 
several  days.  Slow  hemorrhage  is  much  less  serious  than  profuse, 
sudden  bleeding.  Patients  in  early  adult  life  bear  hemorrhage  better 
than  infants  or  the  very  old;  and,  as  a  rule,  women  bear  it  better 
than  men. 

Hemophilia  is  the  name  given  to  an  obscure  condition  affecting 
males  almost  exclusively,  and  seemingly  transmitted  from  one  gener- 
ation to  another  only  through  the  female  sex.  It  is  characterized  by 
an  abnormal  and  inveterate  tendency  to  hemorrhage  even  from  the 
most  trifling  injuries.  Mere  scratches,  the  extraction  of  a  tooth, 
etc.,  frequently  have  caused  such  persons  to  bleed  to  death.  The 
vice  appears  to  reside  in  a  loss  of  coagulability  of  the  blood,  though 

(259) 


200  SURGERY  OF  THE  BLOOD  VASCULAR  SYSTEM 

it  was  long  held  that  the  bloodvessel  walls  were  at  fault.  Blood 
oozes  in  profusion  from  the  capillaries,  and  no  local  remedies  are  of 
much  avail.  The  internal  administration  of  calcium  chloride  may 
be  tried;  and  the  hypodermic  injection  of  horse  or  rabbit  serum,  and 
even  of  diphtheria  antitoxin  has  been  used  in  some  cases  with  benefit. 
Nolf  and  Kerry  (1910)  secured  arrest  of  the  bleeding  in  nine  cases 
by  a  single  hypodermic  injection  of  10  c.c.  of  a  5  per  cent,  solution 
of  peptone  in  0.5  per  cent,  sodium  chloride  solution.  Hypodermoc- 
lysis,  intravenous  injections  of  saline  solution,  and  even  direct 
transfusion  of  blood  may  be  tried.  Plate  II,  Fig.  2,  shows  the  sub- 
cutaneous hemorrhages  which  followed  the  insertion  of  needles  for 
hypodermoclysis  in  a  patient  with  hemophilia  following  circumci- 
sion; in  this  case  recovery  occurred  after  the  direct  transfusion  of 
blood  and  use  of  diphtheria  antitoxin.  Yet  a  year  later  the  patient 
was  again  in  the  ward  with  hemarthrosis  (p.  424)  following  a  trifling 
contusion  of  the  knee. 

Spontaneous  Arrest  of  Hemorrhage. — As  mentioned  above,  bleeding 
sometimes  ceases  spontaneously.  Most  very  small  vessels  cease  to 
bleed  in  a  few  minutes.  In  the  case  of  capillaries,  swelling  of  the 
endothelium  occludes  the  lumen;  in  larger  vessels  there  occur  in 
addition  contraction  and  retraction  of  the  vessel  walls.  Contraction 
of  a  divided  vessel  is  said  to  be  an  effort  to  restore  the  blood  pres- 
sure to  normal.  Retraction  results  from  the  natural  elasticity  of  the 
vessel,  its  ends  being  drawn  back  among  the  tissues,  and  its  walls 
curling  upon  themselves  so  as  to  diminish  the  lumen,  thus  favoring 
coagulation. 

Treatment  of  Hemorrhage. — Temporary  control  of  hemorrhage 
usually  can  be  secured  by  direct  pressure  against  the  bleeding  point, 
or  on  the  main  artery  of  the  part  close  above  the  wound,  with  eleva- 
tion of  the  wounded  part.  When  possible  a  tourniquet  or  Esmarch 
band  (p.  214)  may  be  applied.  For  permanent  control  of  hemorrhage 
the  surgeon  has  many  means  at  his  command. 

1.  Position. — Elevation  of  the  part  has  been  mentioned  already, 
and  should  never  be  neglected.  It  is  a  remedy  so  simple  that  it 
often  is  overlooked.  Hold  the  wounded  extremity  up  in  the  air  until 
help  arrives,  if  you  can't  do  anything  else. 

2.  Pressure. — Direct  pressure  on  the  wounded  vessel  always  can 
be  relied  on  to  check  hemorrhage.  Use  your  finger  if  you  have  noth- 
ing else.  A  graduated  compress  may  be  held  against  the  wTounded 
vessel:  this  is  made  of  pieces  of  gauze  so  cut  as  to  form  a  pyramid 
when  placed  one  on  the  other;  the  apex  of  the  pyramid  is  placed 
against  the  wounded  vessel,  and  the  compress  is  held  in  place  by  a 
tight  bandage.  Hyperflexion  of  the  elbow  or  knee  over  a  compress 
will  control  bleeding  below.  Hemostatic  forceps  (Fig.  153)  or  other 
form  of  clamp  may  be  applied  directly  to  the  wounded  vessel,  and 
in  emergency  the  forceps  may  be  left  in  place  thirty-six  to  forty- 
eight  hours.  If  the  wound  in  the  vessel  cannot  be  found,  com- 
press the  main  artery,  when  possible,  at  a  higher  point.     This,  and 


PLATE    II 


Fig.  1. — Multiple  nevi,  affecting  scalp,  forehead,  left  foot,  etc.,  in  a  baby  aged 
two  and  one-half  months.     Episcopal   Hospital. 

Fig.  2. — Hemophilia,  two  days  after  circumcision,  in  a  boy  aged  eight  years;  show- 
ing subcutaneous  hemorrhages;  that  in  right  thigh  followed  an  attempt  to  give  hypo- 
dermoelysis.     Episcopal   Hospital. 


TREATMENT  OF  HEMORRHAGE  261 

elevation  of  the  part,  will  arrest,  temporarily,  any  hemorrhage.  Or 
the  wound  may  be  packed  with  gauze  or  lint.  Acupressure  (Sir  J.  Y. 
Simpson,  1859)  is  seldom  employed  at  present.  A  long  and  strong 
steel  pin  is  passed  under  the  vessel,  occluding  it  against  the  overlying 
tissues,  as  the  stem  of  a  flower  is  pinned  against  the  coat  lapel;  or  a 
ligature  in  figure-of-eight  fashion  may  be  wound  around  the  two  ends 
of  the  pin,  compressing  the  vessel  between  the  pin  and  the  intervening 
tissues.  Forcipressure  or  angeiotripsy  consists  in  occluding  the  bleeding 
vessels  by  powerful  clamps  which  are  removed  at  once;  they  cause  a 
reactive  inflammation  which  will  occlude  the  lumen.  Skene  (1897) 
and  A.  J.  Downes  (1902)  used  an  electro-thermic  angeiotribe. 

3.  Heat  and  Cold  are  efficient  in  hemorrhage  of  mild  degree. 
Cloths  wrung  out  of  very  hot  water  (120°  F.)  applied  to  the  face  of 
an  oozing  wound  (p.  216)  usually  check  all  capillary  bleeding.  Cold, 
in  the  form  of  ice  caps,  frequently  is  employed  in  gastric  and  intestinal 
hemorrhage;  and  often  is  of  value  in  checking  extravasation  in  the 
subcutaneous  tissues.  The  actual  cautery,  heated  to  a  black  heat 
only,  is  very  efficient  when  other  methods  are  not  available. 

4.  Styptics  are  seldom  used  except  for  oozing.  Alcohol  is  not 
very  active.  Alum,  tannic  acid,  the  perchloride  and  persulphate  of 
iron,  etc.,  are  more  valuable,  especially  when  applied  on  a  graduated 
compress.  Cocain  and  epinephrin  are  employed  on  mucous  mem- 
branes. 

5.  Torsion. — A  bleeding  vessel  may  be  caught  in  forceps  and 
twisted  on  itself  until  the  forceps  is  twisted  off  ("free  torsion";;  or, 
being  caught  higher  up  by  one  forceps,  may  be  twisted  by  another 
("limited  torsion").  In  either  case  the  manoeuvre  succeeds  in  ap- 
proximating the  walls  of  the  vessel  and  in  arousing  sufficient  reaction 
on  the  part  of  the  intima  to  favor  permanent  occlusion.  Vessels  of 
moderate  size  only  should  be  treated  by  torsion;  usually  from  five 
to  six  turns  are  sufficient. 

6.  Ligation. — Ligatures,  like  sutures,  are  of  absorbable  or  non- 
absorbable material.  Usually  catgut  ligatures  are  preferred,  and 
for  large  vessels  chromicized  catgut  is  used,  though  some  surgeons 
prefer  silk  or  linen.  When  a  ligature  is  applied  to  a  vessel  it  constricts 
it  concentrically,  crumpling  its  coats  more  or  less,  and  bringing 
intima  into  contact  with  intima;  owing  to  the  properties  of  this 
serous  surface,  like  that  of  the  peritoneum,  pleura,  etc.,  prolonged 
contact  after  very  moderate  injury  is  sufficient  to  secure  firm  adhesion. 
It  is  not  usually  necessary  to  draw  the  ligature  so  tight  as  to  rupture 
the  inner  and  middle  coats;  it  is  sufficient  to  occlude  the  vessel. 
The  method  of  union  after  firm  apposition  of  the  intima  is  patholog- 
ically identical  with  that  already  described  in  connection  with  the 
repair  of  wounds  as  union  by  adhesion.  The  walls  of  the  vessel, 
with  their  endothelial  cells,  play  a  more  important  part  in  the  process 
than  the  contained  blood;  indeed,  it  is  denied  by  some  pathologists 
that  the  blood  takes  any  part  in  the  process.  The  formation  of  a 
clot  is  not  a  necessary  phenomenon,  and  if  infection  be  absent  firm 


262  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

occlusion  of  vessels  will  occur  without  any  thrombosis;  this  renders 
it  sale  (Guyon,  1868;  Wyeth,  1876),  though  not  always  expedient, 
to  Iigate  large  trunks  close  to  the  origin  of  branches,  or  vice  versa. 
Usually,  however,  a  clot  forms  proximal  to  the  ligature,  and,  if  the 
vessel  has  been  tied  in  its  continuity  (i.  e.,  in  cases  where  the  vessel 
has  not  been  divided),  a  smaller  clot  usually  forms  on  its  distal  side. 
These  clots  lie  rather  loosely  in  the  channel,  and  are  gradually  con- 
verted into  fibrous  connective  tissue  by  organization  (p.  30).  Should 
such  a  clot  extend  from  the  point  of  ligation  past  the  origin  of  a  large 
branch,  there  might  be  danger  of  emboli  being  carried  away  from  it; 
hence  it  usually  is  considered  proper  not  to  apply  a  ligature  within 
1  or  2  cm.  of  a  large  branch. 

Rules  for  Ligation  of  Wounded  Arteries. — These  rules  are  now  classic 
in  surgery,  and  even  today  admit  of  very  few  exceptions: 

1 .  In  cases  of  primary  hemorrhage  do  not  Iigate  the  vessel  unless  it  is 
actually  bleeding  at  the  time.  This  rule  applies  to  primary,  not  to 
secondary  hemorrhage,  and  should  be  observed  because:  (a)  bleeding 
may  never  recur;  (6)  it  is  difficult  to  know  which  artery  to  tie  unless 
the  surgeon  sees  it  bleed;  and  (c)  search  for  the  artery  may  cause 
unnecessary  damage  and  lead  to  infection.  Exceptions:  (a)  if  the 
artery  is  seen  pulsating  in  the  wound  it  should  be  tied  whether  it 
bleeds  or  not:  the  operation  is  easy,  harmless,  and  the  remedy  sure; 
(6)  if  the  patient  has  to  be  transported  a  long  distance  or  will  be  out 
of  reach  of  a  skilful  surgeon,  it  will  be  proper  to  make  a  search  for 
the  vessel  even  if  it  is  not  bleeding  nor  easily  found. 

2.  The  vessel  should  be  ligated  where  it  bleeds  and  not  elsewhere, 
no  matter  what  the  condition  of  the  wound.  Because:  (a)  unless  the 
wounded  vessel  itself  is  seen,  the  surgeon  may  Iigate  the  wrong  vessel 
and  fail  to  check  the  bleeding;  (6)  ligation  even  of  the  proper  vessel 
at  a  higher  point  will  not  prevent  recurrence  of  bleeding  from  the 
distal  end,  nor  from  the  proximal  end  if  a  large  branch  intervenes, 
so  soon  as  the  collateral  circulation  is  established.  There  are  no 
exceptions  to  this  rule  (Guthrie,  1815;  Matas,  1909).  But  in  certain 
regions  (floor  of  the  mouth,  pelvis)  it  may  be  necessary  to  expose 
the  bleeding  point  by  a  counter-incision,  instead  of  through  the 
original  wound. 

3.  Both  ends  of  the  wounded  vessel  should  be  ligated;  and  if  it  is 
only  partly  severed  a  ligature  should  be  applied  each  side  of  the  wound 
and  the  artery  then  divided  between  them.  Because:  when  collateral 
circulation  develops  bleeding  from  the  distal  end  will  occur  even  if 
this  is  not  bleeding  when  the  proximal  is  ligated.  Exceptions:  (a) 
when  the  distal  end  cannot  be  found,  the  wound  should  be  packed 
after  ligation  of  the  proximal  end;  and  (6)  where  both  ends  are  easily 
found,  where  the  injury  was  a  clean  incised  wround,  and  where  occlu- 
sion of  the  the  vessel  might  cause  gangrene,  an  attempt  at  circular 
arteriorrhaphy  (p.  266)  should  be  made. 

4.  Wound  of  a  large  vessel  near  its  origin  requires  ligation  of  the 
wounded  vessel  beloiv  the  icound,  and  of  the  parent  trunk  above  and 


TREATMENT  OF  HEMORRHAGE 


263 


below  the  origin  of  the  wounded  branch  (Fig.  226);  and  wound  of  a 
main  trunk  near  the  origin  of  a  large  branch  requires  ligation  of  the 
wounded  vessel  above  and  below  the  wound  and  ligation  of  the  large 
branch  (Fig.  227).  Because:  in  the  former  case  the  end  of  the 
bleeding  vessel  next  the  main  trunk  is  too  short  to  hold  a  ligature; 
and  in  the  second  case  the  establishment  of  collateral  circulation 
will  cause  the  branch  to  bleed  through  the  wound  of  the  main  trunk 
unless  the  branch  is  ligated.  Exception:  in  case  of  the  main  vessels 
(carotid,  iliac,  femoral,  popliteal),  occlusion  of  which  may  cause 
gangrene,  the  wound  in  the  main  trunk  should  be  sutured,  and  only 
the  collateral  should  be  ligated. 


Fig.  226. — Wound  of  a  large  branch  near 
its  parent  trunk  requires  ligation  of  the 
trunk  above  and  below  the  branch  as  well 
as  of  the  branch. 


Fig.  227. — Wound  of  a  main  trunk 
near  the  origin  of  a  large  branch  requires 
ligation  of  the  branch  as  well  as  of  the 
trunk. 


Method  of  Ligating  Arteries. — Arteries  (and  veins)  may  be  ligated 
in  continuity  or  at  the  seat  of  the  lesion.  In  the  latter  case,  the 
cut  end  is  grasped  with  a  hemostat,  drawn  slightly  out  of  its  sheath 
and  the  ligature  applied  well  above  the  forceps.  When  ligation  is 
done  in  continuity,  an  incision  is  made  slightly  oblique  to  the  known 
course  of  the  vessel,  the  proper  muscular  interspace  is  found,  and 
when  the  sheath  of  the  artery  is  exposed,  it  is  picked  up  by  forceps 
and  cautiously  divided  by  the  edge  of  the  knife  cutting  toward  the 
forceps  (Fig.  22S).  The  threaded  aneurysm  needle  is  then  gently 
insinuated  between  the  artery  and  its  sheath  (entering  on  the  side 
where  lies  the  most  dangerous  structure,  usually  a  vein),1  and  is 
gradually  teased  around  the  artery,  great  care  being  exercised  not 
to  separate  the  sheath  more  extensively  from  the  vessel  than  is 
absolutely  necessary  and  not  to  include  a  neighboring  nerve  in  the 
ligature.  When  the  point  of  the  aneurysm  needle  emerges  on  the 
opposite  side  of  the  artery,  the  loop  of  the  ligature  lying  in  the  con- 
cavity of  the  needle  is  caught  in  forceps  and  pulled  through  (Fig.  228). 
Then  the  aneurysm  needle  is  withdrawn.  An  assistant  then  feels 
for  the  pulsation  of  the  artery  or  its  main  branches  below,  and  the 
surgeon  temporarily  constricts  the  artery  between  the  ligature  and 

1  Vense  comites  may  be  tied  in  with  their  artery. 


261 


SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 


his  finger,  determining  whether  he  is  about  to  tie  the  proper  vessel 
by  its  effect  on  the  pulse  below.  In  the  ease  of  anomalous  high 
division  of  the  brachial  artery,  for  instance,  he  might  be  tying  only 
one  branch  instead  of  the  main  trunk,  as  desired;  and  unless  obliter- 
ation of  the  radial  and  ulnar  pulse  was 
sought  for,  his  error  might  pass  undis- 
covered at  the  time.  Arteries  of  ordi- 
nary size  are  to  be  tied  with  the  square 
knot  (Fig.  116);  very  large  arteries 
(innominate,  iliac,  femoral)  or  those 
which  are  atheromatous,  are  more 
safely  secured  by  the  stay  knot  of 
Ballance  and  Edmunds  (Fig.  229). 


Fig.  228. — Ligation  of  an  artery; 
above,  the  sheath  is  being  opened ;  in 
the  centre,  the  ligature  is  being 
passed;  below,  it  is  being  tied. 


Fig.  229. — The  stay-knot.  A,  double  ligature 
passed  and  each  end  tied  separately;  B,  all  four 
ends  tied  as  if  they  formed  one  ligature. 


Secondary  Hemorrhage. — This  was  defined  and  its  causes  stated  at 
p.  186.  It  is  apt  to  come  from  the  distal  stump  of  a  vessel  ligated  in  con- 
tinuity, and  is  frequently  ushered  in  by  slight  blood-stained  discharges, 
premonitory  of  the  violent  gush  when  the  vessel  finally  gives  way. 

Treatment. — The  treatment  differs  in  some  respects  from  that 
proper  for  primary  hemorrhage.  The  first  rule  given  above  does 
not  apply,  because  hemorrhage  having  once  recurred  is  extremely 
liable  to  do  so  again  unless  active  measures  are  instituted.  The 
surgeon  may  after  the  first,  and  must  after  the  second  bleeding  adopt 
determined  measures  to  prevent  a  return  of  the  hemorrhage  (Erich- 
sen,  1861),  and  should  ligate  both  ends  of  the  abounded  artery  in  the 
wound,  no  matter  what  the  condition  of  that  wound,  whether  or  not  active 
bleeding  is  present  when  the  operation  is  undertaken.  Should  re-ligation 
be  impossible  (as  in  vessels  at  the  root  of  the  neck,  or  in  the  pelvis), 
a  graduated  compress  may  be  applied;  or  neighboring  collaterals 
may  be  ligated,  to  check  the  return  circulation  {e.  g.,  the  vertebral 
in  secondary  hemorrhage  after  ligation  of  innominate.)1  If  secondary 
hemorrhage  recurs  after  re-ligation  in  continuity,  amputation  should 
be  done  at  the  site  of  ligature  in  the  lower  extremity;  while  in  the 
upper  extremity  this  final  step  sometimes  may  be  obviated  by  ligating 


1  Secondary  hemorrhage  recurring  from  an  amputation  stump  requires  re-ampu- 
tation if  ligation  of  the  main  trunk,  of  the  limb  has  failed. 


SUBCUTANEOUS  INJURIES  OF  BLOODVESSELS  265 

the  main  vessel  (brachial,  axillary,  or  subclavian)  at  a  higher  point. 
In  the  lower  extremity  such  a  course  would  surely  cause  gangrene, 
so  amputation  is  better. 

Constitutional  Treatment  of  Hemorrhage. — This  is  very  much  the 
same  as  that  for  shock  (p.  1S4),  especially  valuable  being  elevation 
of  the  pelvis  and  lower  extremities,  autotransfusion,  intravenous 
saline  infusion,  direct  transfusion  of  blood,  and  the  administration 
of  cardiac  stimulants.  According  to  Depage  (1917),  recovery  without 
transfusion  of  blood  will  not  occur  if  the  number  of  erythrocytes  has 
fallen  below  4,000,000  in  the  first  six  hours  after  injury. 

Subcutaneous  Injuries  of  Bloodvessels. — Injuries  of  either  arteries 
or  veins  are  attended  by  reactive  phenomena  which  correspond 
pathologically  to  the  inflammatory  process.  In  cases  of  contusion 
this  reaction  may  cause  thrombosis  of  the  blood  within  the  vessels; 
but  far  more  frequently  the  vessel  is  ruptured  subcutaneously,  caus- 
ing the  formation  of  a  hematoma  (p.  160).  This  may  be  absorbed 
if  small,  but  sometimes  remains  fluid,  may  become  infected  (through 


Fig.  230. — Gangrene  following  ligation  of  both  ends  of  ruptured  femoral  artery  and  vein, 
in  Hunter's  canal.     Amputation.     Recovery.     Episcopal  Hospital. 

the  blood-stream,  from  a  neighboring  viscus,  or  from  the  deeper 
skin  cocci),  and  require  opening  and  drainage.  If  a  hematoma  pro- 
gressively increases  in  size  after  its  formation,  it  is  probable  that  a 
large  vessel  is  ruptured ;  it  will  then  be  proper  to  open  the  hematoma 
and  check  the  hemorrhage.  A  hematoma  due  to  rupture  of  a  large 
vessel  may  cease  to  grow  and  finally  become  encysted,  still  being 
in  communication  with  the  source  of  hemorrhage:  if  this  was  a  vein, 
a  so-called  venous  aneurysm  is  formed;  if  an  artery,  a  circumscribed 
traumatic  aneurysm.  A  diffused  traumatic  aneurysm  is  more  frequent 
in  the  axilla  or  groin,  where  the  tissues  are  more  readily  separated 
by  the  extravasated  blood;  the  blood  in  such  cases  is  more  apt  to 
become  clotted,  and  may  very  seriously  compromise  the  circulation 
of  the  limb.  The  semi-clotted  mass  should  be  evacuated,  and  the 
ruptured  vessels  ligated.  Fig.  230  shows  gangrene  following  ligation 
of  both  ends  of  a  ruptured  femoral  artery  and  vein,  due  to  contusion 
by  a  heavy  steel  plate,  and  accompanied  by  the  formation  of  an 
immense  diffuse  traumatic  aneurvsm. 


266 


SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 


Open  Wounds  of  Bloodvessels.  These  may  be  incised,  punctured, 
etc.,  or  due  to  gunshot  injury.  If  smaller  vessels  have  not  been 
divided  completely  by  the  original  injury,  the  surgeon  should  cut 
them  entirely  across,  and  li^ate  both  ends.  For  punctured  wounds 
of  the  larger  veins  a  lateral  ligature  should  be  applied  (Fig.  231); 
by  bringing  Ultima  into  contact  with  intima,  firm  union  without 
thrombosis  may  be  expected.  If  a  large  vessel,  artery  or  vein,  presents 
an  incised  wound,  and  obliteration  of  the  circulation  by  ligature  is 


Fig.  231. — Application  of  a 
lateral  ligature  for  punctured 
wound  of  vein. 


Fig.  232. — -Circular  arteriorrhaphy  by  Carrel's 
method :  when  the  three  stay  sutures  are  pulled  taut, 
the  introduction  of  the  sutures  is  much  facilitated. 


likely  to  result  in  gangrene  (as  is  especially  the  case  in  the  popliteal, 
femoral,  and  axillary  arteries),  attempt  should  be  made  to  suture 
the  wound  in  such  a  way  as  to  evert  its  edges,  thus  apposing  serous 
surfaces.  Should  such  a  vessel,  especially  an  artery,  be  completely 
divided,  circular  arteriorrhaphy  should  be  done  (Fig.  232),  using  a  very 
fine  round-pointed  needle  and  No.  500  silk,  soaked  in  sterile  vaselin 
(Carrel,  1902).  The  circulation  is  controlled  by  Crile's  clamps  (Fig.233), 


Fig.  233. — Crile's  clamp  for  temporary  occlusion  of  bloodvessels,  blades 
covered  with  rubber. 


applied  directly  to  the  wTounded  vessel.  Even  if  thrombosis  follows 
the  attempt,  occlusion  of  the  artery  will  be  so  gradual  that  gangrene 
will  be  much  less  apt  to  ensue  than  after  ligation.  Should  ligation 
of  the  main  vein  of  a  limb  be  necessary,  the  main  artery  should  not 
be  ligated  also;  to  do  so  increases  the  risk  of  gangrene  (p.  273). 
Gunshot  and  other  contused  wounds  rarely  admit  of  suture. 

Entrance  of  air  into   veins  is  no   longer  regarded    as   a  frightful 
calamity,  presaging  immediate  death.     In  operating  at  the  root  of 


OPEN  WOUNDS  OF  BLOODVESSELS 


267 


the  neck,  where  negative  pressure  in  the  veins  during  inspiration  is 
most  marked,  air  may  be  sucked  into  the  circulation,  and  when  in 
large  quantity  has,  in  a  few  instances,  been  productive  of  serious 
consequences.  A  sucking,  lapping,  or  gurgling  sound  is  heard,  closely 
following  a  gush  of  blood  from  the  wounded  vein,  and  sometimes 
followed  by  the  appearance  of  frothy  blood  in  the  wound.1  Pale- 
ness and  lividity,  failure  of  the  circulation  and  collapse  may  ensue. 
In  operations  in  the  "danger  zone"  the  surgeon,  if  possible,  should  apply 
a  compress  to  the  region  where  the  internal  jugular  and  subclavian 
veins  unite,  thus  causing  back  pressure  on  the  main  trunks  above; 
this  facilitates  dissection.  When  the  accident  occurs,  plug  the  open- 
ing with  the  finger  until  other  means  of  arresting  the  hemorrhage  can 
be  applied. 


Fig.  234. — Direct  arteriovenous  fistula 
(aneurysmal  varix) . 


Fig.  235. — Indirect  arteriovenous  fistula 
(varicose  aneurysm). 


Arterio-venous-  wounds  occasionally  occur  from  puncture,  stab, 
or  gunshot  injury  involving  both  artery  and  vein.  The  superficial 
parts  may  heal,  leaving  a  form  of  traumatic  arterio-venous  aneurysm: 
if  the  artery  and  vein  are  in  direct  communication,  the  condition 
is  known  as  aneurysmal  varix  (Fig.  234);  if  a  sac  intervenes,  it  is  a 
varicose  aneurysm  (Fig.  235) .2  The  diagnosis  in  either  case  depends 
on  the  history  of  injury,  and  the  rather  tardy  development  of  signs 
of  a  traumatic  aneurysm,  accompanied  by  a  susurrus,  or  purring 
thrill,  and  in  the  case  of  a  varicose  aneurysm  by  a  distinct  impulse 
and  aneurysmal  whirr.  The  buzzing  is  continuous,  not  disappear- 
ing entirely  during  diastole  (except  sometimes  when  the  limb  is 
elevated  —  Nelaton),  but  being  accentuated  during  systole;  the 
murmur  is  transmitted  centrifugally,  sometimes  centripetally,  and 
the  superficial  veins  may  pulsate  (Matas).  An  aneurysmal  varix 
rarely  gives  much  distress,  except  for  the  buzzing  sensation  on  palpa- 


1  A  somewhat  similar  sound,  but  no  bleeding,  follows  injury  of  the  pleura. 
2 The  terminology  of  John  B.  Roberts  (arterio-venous  fistula,  director  indirect)  is 
preferable. 


268  SURGERY  OF  THE   BLOOD   VASCULAR  SYSTEM 

tion;  this  may  be  audible  to  the  patient;  but  the  tumor  seldom 
enlarges,  and,  as  a  rule,  only  palliative  treatment  is  required.  If 
necessary,  however,  the  surgeon  may  attempt  separation  of  the 
vessels  and  suture  or  ligation  of  the  defeets.  A  varicose  aneurysm, 
on  the  other  hand,  is  prone  to  grow  larger  progressively,  and,  though 
rarely  reaching  very  large  size,  in  many  respects  resembles  an  ordinary 
aneurysm.  Operation  generally  is  indicated;  this  may  consist  merely 
in  ligation  of  the  more  accessible  vessel  (preferably  the  artery)  above 
and  below  the  sac,  or  in  extirpation  of  the  sac  and  suture  of  the  venous 
and  arterial  orifices;  better  still  (Bickham,  1904)  would  be  oblitera- 
tion of  the  sac  by  endo-aneurysmorrhaphy  (p.  288).  Conners  (1918) 
sacrifices  the  vein,  using  it  as  a  patch  to  repair  the  arterial  defect. 
For  the  success  of  most  of  these  methods,  preliminary  control  of  the 
circulation  is  necessary;  where  this  is  impossible,  even  by  the  use  of 
( 'rile's  (Fig.  233)  or  some  similar  clamp,  the  surgeon  must  open  the  sac, 
plug  the  arterial  orifice  with  his  finger,  and  apply  a  suture  to  occlude 
the  orifice  as  quickly  as  possible;  the  venous  opening  is  next  closed. 

Injuries  of  the  Heart.-  Rupture. — Rupture  of  the  heart  may  be  due 
to  injury  or  disease.  Blood  is  pumped  into  the  pericardium,  causing 
embarrassment  of  cardiac  action,  with  dyspnea,  cyanosis,  collapse, 
and  death,  before  suture  of  the  rent,  which  is  indicated,  can  be 
attempted. 

Wounds. — Wounds  of  the  heart  are  usually  stab  or  gunshot  wounds. 
In  cases  coming  to  operation,  the  left  ventricle  is  most  often  wounded, 
generally  on  the  left  of  the  sternum.  The  symptoms  are  much  the 
same  as  those  of  rupture  of  the  heart,  though  somewhat  less  severe; 
if  the  patient  does  not  die  within  a  few  minutes,  he  usually  survives 
several  hours,  affording  opportunity  for  rational  treatment.  Wounds 
of  the  pleura  (40  to  70  per  cent.)  and  of  the  lung  (30  to  50  per  cent.), 
may  coexist,  and  pericardial  hemorrhage  may  come  from  this  source, 
and  not  from  a  wound  of  the  heart  itself.  In  all  cases  in  which  car- 
diac injury  is  suspected,  however,  exploratory  pericardiotomy  should 
be  done.  Where  no  precordial  wound  exists,  Matas  (1909)  advises 
an  oblique  incision,  from  the  mid  sternum  opposite  the  fourth  inter- 
space, downward  and  toward  the  left,  dividing  the  fifth  or  sixth 
costal  cartilage,  which  is  excised.  When  an  external  wound  makes 
the  diagnosis  more  certain,  Spangaro's  incision  (1906)  in  the  fourth 
intercostal  space  is  preferable;  this  extends  from  the  left  margin  of 
the  sternum  out  as  far  as  necessary,  the  pleura  being  opened  if  already 
wounded.  If  sufficient  exposure  is  not  obtained  by  forcible  retraction 
of  the  ribs,  the  costal  cartilages  above  and  below  may  be  divided 
close  to  the  sternum.  The  pericardium  being  opened  and  clots 
evacuated,  the  slippery  heart  is  grasped  in  the  left  hand,  and  the 
wound  sutured  with  a  continuous  chromic  gut  suture,  hemorrhage 
being  intermittently  controlled  by  pressure  on  the  vena?  cavae  at 
their  entrance  into  the  right  auricle  (Rehn,  1907).  Drainage  should 
be  avoided  until  subsequently  required  for  infection.  Simon  collected 
(up  to  1912)  241  operations  for  gunshot  wounds,  with  124  deaths 


THROMBOSIS  AND  EMBOLISM  269 

(51  per  cent,  mortality) ;  and  200  operations  for  stab  wounds,  with 
99  deaths  (49  per  cent.). 

Foreign  Bodies. — Foreign  bodies  in  the  heart  have  been  recorded 
in  over  100  cases.  Most  have  been  portions  of  needles  or  encysted 
bullets.  The  diagnosis  and  localization  are  aided  by  radiography; 
and  extraction  by  cardiotomy  is  indicated  if  any  symptoms  are  present. 

Cardiolysis  is  an  operation  proposed  by  Brauer  (1902),  and  employed 
by  Petersen,  Simon,  Morison,  and  others,  consisting  in  excision  of 
portions  of  the  fifth  and  sixth  left  ribs  to  allow  more  room  for  expan- 
sion of  a  heart  hypertrophied  from  aortic  disease;  much  improvement 
in  symptoms  is  said  to  have  resulted.  Haberer  (1910)  employed 
a  similar  operation  for  chronic  adhesive  pericarditis;  while  others 
have  gone  further,  opening  the  pericardium  and  freeing  its  adhesions. 
Leriche  and  Cotte  (1909)  refer  to  18  operations  of  the  latter  type, 
with  marked  improvement  in  all  cases. 

Pericardiotomy  may  be  required  for  serous  or  purulent  effusion 
in  the  pericardium.  A  trocar  may  be  introduced  for  diagnosis  close 
to  the  sternum  in  the  fourth,  fifth  or  sixth  left  interspace,  according 
to  the  physical  signs,  or,  which  is  preferred  by  Matas,  at  the  left  side 
of  the  base  of  the  ensiform.  If  pus  is  found  a  formal  incision  is  made, 
dividing  the  sixth  and  seventh  left  costal  cartilages  close  to  the  ster- 
num, and  a  drain  tube  is  introduced.  A  series  of  22  cases  of  pericardi- 
otomy gave  a  mortality  of  32  per  cent.  (Elliott,  1909). 

Massage  of  the  heart  should  be  employed  in  cases  of  sudden  arrest 
of  its  action  during  surgical  operations.  Through  an  epigastric  inci- 
sion the  hand  grasps  the  heart  from  beneath  the  diaphragm.  Jurasz 
(1911)  referred  to  64  recorded  cases,  with  13  permanent  and  15  tem- 
porary recoveries. 

DISEASES  OF  THE  BLOOD  VASCULAR  SYSTEM. 

Thrombosis  and  Embolism. — When  blood  coagulates  within  the 
vessels  during  life,  the  process  is  called  thrombosis,  and  the  resulting 
clot  a  thrombus.  It  is  recognized  clinically  that  there  may  be  an 
aseptic  as  well  as  a  septic  thrombosis,  though  the  former  becomes 
rarer  the  more  we  learn  of  the  subject.  Infection  may  reach  the 
region  of  thrombosis  through  the  blood-stream,  or  by  contiguity 
from  neighboring  parts;  in  the  latter  case  it  is  customary  to  incrimi- 
nate the  perivascular  lymphatics  and  the  vasa  vasorum  as  the  avenue 
of  approach.  Accepting,  then,  infection  as  the  exciting  cause  of 
thrombosis,  we  admit  as  predisposing  causes  anything  which  sloivs  the 
blood-stream,  which  produces  changes  in  the  vessel  walls,  or  in  the  com- 
position of  the  circulating  blood.  The  most  important  of  these  three 
doubtless  is  changes  in  the  vessel  walls;  and  these  changes  in  most 
instances  are  due  to  bacteria  or  their  toxins.  Aseptic  injury  seldom 
is  a  cause  of  thrombosis  (p.  261).  Moreover,  changes  in  the  vessel 
walls,  as  in  atheroma,  phlebectasis,  etc.,  also  act  by  obstructing 
the  blood-current;  and  when  the  composition  of  the  blood  is  altered 
by  disease  {e.  g.,  infections  such  as  typhoid  fever,  appendicitis,  sup- 


270  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

putative  inflammations;  metabolic  poisons,  as  in  eclampsia,  after 
burns,  etc.),  or  by  injury  (as  after  profuse  hemorrhages),  very  slight 
retardation  may  be  sufficient  to  cause  thrombosis.  The  thrombus 
formed  of  circulating  blood,  within  the  vessels,  is  either  of  the  white 
or  mixed  variety:  that  is,  it  contains  relatively  few  erythrocytes, 
as  these  flow  in  the  axial  blood-stream  furthest  from  the  vessel  walls 
where  thrombosis  is  inaugurated  by  depositon  of  blood-platelets, 
destruction  of  leukocytes,  and  formation  of  fibrin  ferment.  The 
thrombus  thus  formed  may  be  a  parietal  thrombus  only,  not  occlud- 
ing the  entire  vascular  lumen,  or  it  may  be  a  complete  or  obstructing 
thrombus.  In  either  case  portions  may  be  broken  off  by  external 
injury  or  simply  by  force  of  the  circulation;  and  such  an  embolus, 
being  carried  away  in  the  blood-stream,  ma}',  when  it  is  arrested 
{embolism),  produce  a  secondary  thrombus,  so  named  in  contradistinc- 
tion to  the  original  primary  thrombus.  The  thrombus,  whether  primary 
or  secondary,  undergoes  in  time  certain  changes  analogous  to  organiza- 
tion, cicatrization,  and  contraction,  as  studied  in  Chapter  I;  by  these 
processes  the  vessel  affected  becomes  converted  into  a  solid  fibrous 
cord  of  connective  tissue.  Occasionally  small  parietal  thrombi  are 
absorbed;  rarely  obstructing  thrombi  become  canalized  by  the  gradual 
development  in  them  of  capillaries  which  subsequently  dilate  and 
re-establish  permeability  for  the  blood-stream;  not  seldom  infective 
thrombi  disintegrate  by  suppuration,  and  then  the  emboli  derived  from 
such  a  thrombus  may  cause  metastatic  abscesses  (p.  70).  Finally, 
thrombi  may  become  calcified,  especially  in  veins,  where  they  are 
converted  into  phleboliths. 

Phlebitis. — Phlebitis,  or  inflammation  of  a  vein,  is  due  in  general 
to  the  same  factors  mentioned  above  as  causing  thrombosis;  and, 
as  may  readily  be  understood  from  wThat  was  there  said,  thrombosis 
is  a  much  more  frequent  occurrence  in  veins  than  in  arteries.  Venous 
blood  normally  clots  more  quickly  than  arterial;  the  normal  venous 
current  is  slow,  is  opposed  by  the  force  of  gravity  and  by  the  valves 
in  the  veins;  superficial  veins  are  not  supported  by  the  muscles, 
and  thus  liable  to  trauma  and  to  extension  of  infection  from  the 
skin  and  its  lesions;  and  their  walls  are  thin,  and  liable  to  be  varicose, 
thus  forming  pouches  where  the  blood  eddies  and  stagnates.  In 
spite  of  all  these  factors  which  predispose  to  primary  thrombosis, 
it  is  not  impossible  for  phlebitis  to  exist,  at  least  for  a  time,  without 
thrombus  formation.  Thus  in  many  cases  of  varicose  veins  (p.  274) 
there  is  chronic  phlebitis  {phlebosclerosis) ,  with  marked  thickening 
of  the  venous  wralls,  yet  without  thrombosis.  Such  cases  probably 
are  due  to  the  action  of  metabolic  poisons,  not  to  septic  infection, 
unless  this  is  extremely  attenuated.  Surgeons  thus  distinguish 
clinically  between  plastic  and  infective  or  septic  phlebitis,  the  latter 
being  accompanied  in  practically  all  cases  by  thrombosis,  and  running 
a  much  more  acute  course. 

The  thrombus  which  forms  in  a  vein  as  a  ride  extends  rather  rapidly 
in  the  direction  of  the  blood-current,  invading  not  infrequently  the 


THROMBOSIS  AND  EMBOLISM 


271 


nearest  branches  in  the  thrombotic  process;  the  clot  extends  also  but 
to  a  less  degree  on  the  distal  side  of  the  obstruction.  Thus  throm- 
bosis beginning  in  the  long  saphenous  vein  behind  the  internal  malleo- 
lus, or  in  the  lower  leg,  may  extend  to  the  femoral;  and  from  this 
the  iliac  veins  and  even  the  vena  cava  may  become  thrombosed. 
Thrombosis  commencing  in  the  appendicular  veins  may  extend  to 
the  portal  vein  and  into  the  liver.  Thrombosis  commencing  in  the 
facial  or  angular  vein  may  extend  to  the  cerebral  sinuses;  and  throm- 
bosis commencing  in  the  lateral  sinus  frequently  extends  into  the 
internal  jugular  vein. 

Symptoms. — These  are  the  usual  symptoms  of  inflammation,  more 
or  less  localized  to  the  known  course  of  a  vein.  Pain  frequently 
is  the  first  symptom  to  attract 
attention;  examination  soon  after 
discloses  heat,  a  dusky  redness  in 
the  line  of  the  veins ;  and  often  the 
thickened,  tender,  cord-like  vein 
can  be  palpated  through  the  over- 
lying tissues.  Great  gentleness 
must  be  used  in  examination,  for 
fear  of  detaching  an  embolus. 
Sometimes  the  position  of  the 
valves  can  be  recognized  by  the 
presence  of  knobby  protuberances. 
Very  rarely  suppuration  occurs, 
multiple  abscesses  forming  along 
the  course  of  the  vein.  There  is 
moderate  swelling  from  the  first, 
and  if  thrombosis  is  complete, 
and  especially  if  a  main  trunk 
is  involved,  there  is  a  certain 
amount  of  edema  in  the  parts 
beyond.  In  advanced  cases  there 
is  total  disability  of  the  affected 
extremity.  The  disease  lasts  from 
one  to  three  or  four  weeks.  Per- 
manent occlusion  of  the  affected 
veins  results  in  compensatory 
dilatation  of  collaterals,  which 
may  themselves  be  the  cause  of  annoyance  or  disability  (Fig.  236). 

Diagnosis. — Predisposing  causes  must  be  considered  (infections, 
injury),  and  the  physical  signs  must  be  accurately  noted.  By  the 
latter  means  phlebitis  may  be  distinguished  from  (1)  Lymphanc/eitis 
(p.  299),  where  the  redness  is  more  flame  colored,  where  the  inflam- 
mation seems  more  superficial,  where  it  does  not  follow  the  known 
course  of  a  vein,  where  a  thickened  knobby  cord  cannot  be  palpated, 
and  where  lymphadenitis  is  a  frequent  accompaniment;  from  (2) 
Periosteitis   and    Osteomyelitis,  where   the    superficial  veins   are   not 


Fig.  236. — Epigastric  varicosities  fol- 
lowing typhoid  thrombosis  of  iliac  veins. 
Episcopal  Hospital. 


272  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

affected,  where  tenderness  and  pain  are  limited  to  the  bone  affected, 

not  extending  past  the  nearest  joint;  where  history  of  direet  trauma 
is  frequent;  and  where  tapping  the  suspected  bone  almost  at  any 
part  of  its  shaft  is  productive  of  pain  at  the  seat  of  greatest  disease; 
and  from  (3)  Neuralgia  and  Neuritis,  where  the  symptoms  are 
localized  to  the  known  course  of  a  nerve,  and  where  no  physical 
signs  of  inflammation  are  present. 

Post-operative  Phlebitis  has  laparotomy  as  its  most  frequent  cause, 
and  usually  affects  the  veins  of  the  left  lower  extremity.  It  not 
infrequently  occurs  after  apparently  aseptic  operations,  and  it  runs 
a  comparatively  mild  course. 

Phlegmasia  Alba  Dolens  is  a  term  used  to  describe  inflammation 
of  the  veins  and  lymphatics,  usually  of  the  left  lower  extremity, 
and  generally  due  to  puerperal  sepsis  ("milk  leg").  The  usual  signs 
of  phlebitis  are  present,  but  the  disease  is  characterized  especially  by 
the  marked  edema,  rendering  the  skin  tense  and  shiny,  probably  due 
to  coincident  diffuse  angeioleucitis;  and  by  the  pallor  of  the  affected 
extremity. 

Treatment. — Phlebitis  is  a  serious  disease,  and  requires  efficient 
treatment.  Local  rest,  which  usually  implies  confinement  to  bed, 
and  elevation  of  the  limb,  should  be  insisted  on.  Gentle  support, 
as  by  flannel  bandages,  aids  elevation  in  preventing  excessive  edema. 
Local  applications  have  little  appreciable  effect,  but  the  use  of  ice 
bags  in  the  early  stages,  and  of  heat  later,  usually  is  grateful  to  the 
patient.  Ichthyol  or  mercury  and  belladonna  ointment  may  be 
applied  to  the  seat  of  greatest  inflammation.  The  skin  should  be 
kept  clean,  and  well  dried,  by  washing  gently  with  alcohol  once  every 
other  day  or  so;  but  under  no  circumstances  should  massage  be 
attempted,  and  none  but  the  very  gentlest  passive  movement  of  the 
extremity  should  be  allowed.  Absolute  rest  of  the  affected  part 
should  be  maintained  for  at  least  one  week  after  all  symptoms  have 
subsided.  If  the  leg  is  affected  there  will  be  persistent  edema  for 
many  wreeks  or  months  after  the  patient  gets  about,  and  an  elastic 
stocking  or  firm  bandaging  will  be  necessary  to  promote  ease  in 
locomotion.    General  treatment  is  the  same  as  in  any  acute  infection. 

The  treatment  above  described  is  sufficient  in  the  immense  majority 
of  cases  of  plastic  phlebitis;  but  in  some  cases  of  septic  phlebitis  it  is 
proper  to  attempt  to  prevent  the  further  spread  of  the  thrombotic 
process  by  excising  a  portion  of  the  main  venous  trunk  some  distance 
on  the  cardiac  side  of  the  furthest  limits  of  inflammation.  Thus  for 
thrombosis  extending  up  the  long  saphenous  vein,  this  trunk  may  be 
doubly  ligated  and  a  section  excised  (Fig.  237),  or  the  vein  simply 
divided,  at  the  saphenous  opening.  In  thrombosis  of  the  lateral 
sinus,  following  otitis  media,  it  is  the  rule  to  divide  the  internal 
jugular,  where  healthy,  between  two  ligatures;  and  some  surgeons 
advise  ligating  all  branches  and  excising  as  much  as  possible  of  the 
thrombosed  venous  channels.  In  septic  thrombosis  of  the  ovarian 
veins,  following  puerperal  metritis,  many  surgeons  have  attempted  to 


ARTERIAL  EMBOLISM 


273 


prevent  propagation  of  the  thrombus  by  ligation  above  the  limit  of 
disease  (Chapter  XXIX).  The  operation  of  phlebotomy,  with  extrac- 
tion of  the  clot  and  suture  of  the  vein  is 
not  so  promising  as  arteriotomy  for 
arterial  embolism  (p.  274),  as  the 
intima  of  the  thrombosed  vein  is  so 
diseased  as  almost  necessarily  to  ensure 
recurrence  of  thrombosis;  nor  is  the 
operation  so  desirable,  since  gangrene 
is  less  to  be  feared  than  from  arterial 
occlusion.  Wolff  (1908)  showed  that 
in  the  lower  extremity  operative  occlu- 
sion of  the  main  arteries  (137  cases) 
caused  gangrene  in  20  per  cent,  of 
cases;  while  occlusion  of  the  femoral 
vein  alone  (3b  cases)  resulted  in  gan- 
grene in  less  than  (i  per  cent.  *In  the 
upper  extremity  arterial  occlusion  (153 
cases)  caused  gangrene  in  about  8  per 
cent.;  only  one  case  of  ligation  of  the 
(axillary)  vein  was  recorded,  which  did 
not  result  in  gangrene. 

Pulmonary  Embolism.  —  Pulmonary 
embolism,  sometimes  an  alarming  con- 
sequence of  venous  thrombosis,  and 
often  occurring  at  the  onset  of  post- 
operative convalescence,  has  been  considered  at  p.  187.  Other  forms 
of  venous  embolism,  affecting  the  viscera  (especially  the  liver),  are  of 
comparatively  little  surgical  interest,  except  when  occurring  in  pyemia. 

Arterial  Thrombosis. — Arterial  thrombosis  occurs  as  a  complication 
of  wounds,  compound  fractures,  cellulitis,  etc.;  but  unless  affecting 
the  main  artery  of  a  limb,  which  is  rare,  its  symptoms  usually  are 
overshadowed  by  those  of  the  causative  condition.  When  the  main 
artery  of  a  limb  is  affected,  the  symptoms  differ  only  in  the  less  sudden 
onset  from  those  of  arterial  embolism,  presently  to  be  described. 
F.  T.  Stewart  (1908)  refers  to  35  cases  of  traumatic  arterial  thrombosis, 
31  of  which  terminated  in  gangrene.  The  treatment  is  the  same  as 
for  embolism. 

Arterial  Embolism. — Arterial  embolism,  when  affecting  the  main 
artery  of  a  limb,  is  a  condition  of  great  gravity.  The  clot  usually 
is  derived  from  one  of  the  cardiac  valves  in  a  patient  with  ulcera- 
tive endocarditis;  it  is  detached  from  no  apparent  exciting  cause, 
is  carried  away  in  the  blood-stream,  and,  if  lodging  so  as  to  plug  an 
artery  of  considerable  size,  presents  characteristic  and  well-marked 
symptoms.  The  patient  suffers  a  sudden,  acute,  stinging  pain  below 
the  site  of  embolism,  in  the  distribution  of  the  affected  artery;  the 
limb  below  becomes  tingling,  numb,  or  for  a  time  the  seat  of  burning 
pain;  pulsation  is  absent  below  the  site  of  embolism;  and  the  limb 
IS 


Fig.  237. — -Portion  of  thrombosed 
internal  saphenous  vein,  excised  at 
its  juncture  with  the  femoral. 
Episcopal  Hospital. 


271 


SI  HUKHY   OF   THE  BLOOD    VASCULAR  SYSTEM 


gradually  grows  cold,  bluish,  livid,  and  the  signs  of  oncoming  gan- 
grene appear  (p.  60).  Fig.  20  (p.  61)  shows  gangrene  due  to  lodgment 
three  weeks  previously  of  an  embolus  in  the  popliteal  artery,  in  a 
patient  who  three  months  before  had  embolism  of  a  cerebral  artery. 
Treatment. — When  the  embolus  lodges  in  an  accessible  situation, 
and  in  one  where  sudden  complete  arterial  occlusion  habitually 
results  in  gangrene  (especially  the  brachial  at  the  elbow,  the  femoral 
and  popliteal  arteries),  the  surgeon  should  lose  no  time  in  resorting 
to  arteriotomy  and  extraction  of  the  clot  (F.  T.  Stewart,  1908). 
This  is  a  more  promising  procedure  for  embolism  with  secondary 
thrombosis,  than  for  primary  thrombosis,  since  the  healthier  con- 
dition of  the  arterial  coats  in  the  former  condition  makes  recurrence 
of  thrombosis  less  likely.  A  number  of  unsuccessful  operations  are 
on  record,  but  one  successful  case  of  arteriotomy  for  femoral  embolism 
(aseptic)  has  been  reported  by  Mosny  and  Dumont  (1911). 

Varix,  Phlebectasis,  or  Varicose  Veins,  describes  a  condition  in 
which  the  veins  become  elongated,  dilated,  tortuous,  and  pouched.    Any 

veins  may  be  affected,  even  those  of 
bone;  but  superficial  veins,  especially 
the  veins  of  the  spermatic  cord  and 
the  saphenous  veins  of  the  lower  ex- 
tremities, are  most  noticeably  diseased 
(Fig.  238).  The  chief  cause  is  gravi- 
tation, aided  by  obstruction  to  the 
normal  venous  current.  Occupation 
(barbers,  waiters,  motormen,  or  others 
who  stand  for  hours  at  a  time),  tumors, 
pregnancy,  thrombosis  (Fig.  236),  or 
other  factors  producing  obstruction, 
are  all  predisposing  causes.  Usually 
no  one  well  defined  cause  can  be  found. 
The  valves  become  incompetent,  the 
blood  stagnates,  hypertrophy  and  scle- 
rosis of  the  vessel  walls  occur,  phle- 
boliths  may  develop,  and  thrombosis 
may  finally  cause  obliteration  of  the 
diseased  veins.  The  symptoms  of  pain,  fulness,  weight,  etc.,  are  fre- 
quently disabling;  in  the  lower  extremities  the  perivascular  tissues 
become  thickened,  hard  edema  develops,  the  nutrition  of  the  skin 
suffers;  trifling  trauma  produces  an  abrasion  which  fails  to  heal,  and 
varicose  ulcer  results  (p.  57).  Profuse  hemorrhage  may  occur  from 
spontaneous  rupture  of  a  varix.  Rupture  of  a  deep  varicose  vein  is 
attended  by  sudden  stinging  pain  ("coup  de  fouet")  and  subsequent 
appearance  of  ecchymosis.  Treatment  may  be  palliative  or  radical. 
The  former  includes  application  of  elastic  bandages  or  stockings,  after 
emptying  the  veins  and  reducing  edema  by  elevation  of  the  limb; 
the  use  of  stimulating  liniments,  etc.;  and  attention  to  hygiene. 
Such  treatment  always  should  be  tried  first,  and  usually  is  efficient 


Fig.  238. — Varicose  internal 
saphenous  vein,  aged  sixty-three 
years;  duration  over  forty  years. 


VARICOSE  VEINS  275 

when  the  cause  of  the  obstruction  is  temporary  (pregnancy),  or  remov- 
able (tumor,  etc.).  In  other  cases,  or  when  palliative  measures 
fail  to  relieve  symptoms,  operation  is  indicated.  If  the  superficial 
veins  are  varicose  as  a  result  of  thrombotic  obstruction  of  the  deep 
veins,  no  operation  should  be  attempted  unless  elastic  support 
with  temporary  obliteration  of  the  varicosities  produces  relief  and 
demonstrates  the  efficiency  of  the  collateral  circulation.  Very  occa- 
sionally varicosities  due  to  this  cause  disappear  spontaneously 
after  a  few  vears,  owing  to  the  development  of  collateral  circulation 
(Skillern,  1913). 

Operative  Treatment. — Operative  treatment  consists  in  obliteration 
of  the  varicose  channels  at  one  or  several  points.  Scheie's  operation 
(1877)  is  done  by  making  a  circular  incision  below  the  knee  down  to 
the  deep  fascia,  thus  dividing  all  the  superficial  veins;  both  ends  of 
each  divided  vessel  are  then  ligated,  and  the  skin  sutured.  This 
operation  also  divides  the  superficial  lymphatics  and  sensory  nerves; 
sometimes  is  followed  by  edema,  paresthesias,  neuralgias,  or  trophic 
disturbances  in  the  skin  below;  and,  according  to  Matas,  is  followed 
by  permanent  cure  in  only  one-third  of  the  cases.  Spiral  division  of 
the  skin  enables  the  surgeon  to  obliterate  all  the  venous  channels 
without  severing  all  the  lymphatics,  thus  rendering  edema  less 
likely;  but  section  of  the  nerves  can  scarcely  be  avoided.  Tren- 
delenburg's operation  (1S90)  consists  in  division  of  the  main  varicose 
trunk  (usually  the  long  saphenous  above  the  knee)  between  two 
ligatures,  the  object  being  to  break  the  column  of  blood,  thus  relieving 
pressure  symptoms.  It  is  suitable  for  those  cases  where  only  the 
main  trunk,  not  its  collaterals,  is  varicose;  and  is  not  suitable  even 
for  those  cases  if  the  saphenous  vein  is  the  seat  of  chronic  phlebitis. 
According  to  Matas,  79  per  cent,  of  patients  treated  by  Trendelen- 
burg's operation  have  been  cured  or  greatly  improved.  Multiple 
Phlebectomy,  associated  with  the  names  of  Madelung  (1884)  and 
Schwartz  (1888),  is,  I  believe,  the  best  operation  in  the  vast  major- 
ity of  cases.  Sections  of  the  diseased  veins,  7  to  10  cm.  long,  are 
removed  at  the  saphenous  opening  and  in  other  parts  of  the  thigh 
and  leg,  wherever  the  main  trunks  or  their  branches  are  most  dilated; 
the  intervening  portions  become  thrombosed,  contract,  and  produce 
no  further  symptoms;  and  the  greater  portion  of  the  diseased  tissue 
is  completely  removed  from  the  body,  which  is  not  accomplished  by 
either  Schede's  or  Trendelenburg's  operation.  If  the  surgeon  wishes, 
he  can  remove  the  entire  saphenous  vein  through  one  long  incision; 
or  the  entire  vein  may  be  removed  through  three  or  four  small  inci- 
sions by  subcutaneous  tunneling:  Keller  (1905)  passed  a  probe  into 
the  lumen  of  the  vessel,  attached  the  sectioned  end  of  the  vein  to  the 
probe,  and  applied  traction  "until  the  vein  is  completely  extirpated 
by  being  turned  inside  out  and  withdrawn  from  its  sheath."  C.  H. 
Mayo  (1906)  accomplishes  the  same  result  by  passing  a  curette  over 
the  ligated  end  of  the  main  trunk,  and  thus  ripping  off  its  attachments. 
These  methods,  though  more  spectacular  than  multiple  phlebectomy, 


276 


SURGERY   OF   THE   BLOOD    \ASCl  LAR  SYSTEM 


which  is  a  tedious  procedure,  are  less  sure,  since  the  diseased  collaterals 
are  left  behind.  In  many  cases,  moreover,  the  veins  are  calcareous, 
and  so  densely  adherent  to  the  perivascular  tissues  and  even  to  the 
skin,  that  only  a  formal  dissection  can  free  them.  I  have  always 
employed  multiple  phlebectomy,  except  in  cases  due  to  thrombosis  of 
the  dee])  veins;  in  these  I  have  adopted  a  spiral  incision  for  Schede's 
operation,  thus  avoiding  excision  of  the  only  veins  the  patient 
possessed.  Operations  for  varicose  veins  are  not  entirely  devoid  of 
danger:  in  large  series  of  operations  death  from  pulmonary  embolism 
has  occurred  in  1  or  2  per  cent,  of  cases;  the  skin  frequently  is  difficult 
to  sterilize,  and  in  spite  of  care  infection  of  the  incisions  may  occur; 
occasionally  phlebitis  is  a  sequel. 

Hemangiomas;  Telangiectases. — Under  these  terms  are  included 
various  affections  of  the  vascular  system,  whose  proper  classification 
has  not  been  determined  by  pathologists.  In  the  vast  majority  of 
cases  they  are  congenital,  or  at  least  are  noticed  first  in  early  infancy; 
the  lesions  usually  enlarge  more  rapidly  than  the  part  in  which  they 
are  situated,  and  from  being  insignificant  specks  at  birth  may  become 
growths  of  alarming  size  in  childhood  or  early  adult  life.  Sometimes 
they  assume  the  character  of  tumors,  as  described  in  Chapter  IV, 
very  occasionally  seeming  to  possess  malignant  characteristics  (in- 
filtration, recurrence). 

Nevus  Vasculosus. — This  may  affect  either  capillaries  or  venules, 
its. color  (bluish,  purplish,  or  red)  depending  upon  the  proportion  of 
venous  blood  present. 

Capillary  Nevi  (Plate  II,  Fig.  1,  p.  260) .—Capillary  nevi  occur  in  the 
skin,  rarely  in  mucous  membranes;  they  do  not  involve  the  subcutaneous 

tissues;  they  are  red,  or  reddish  blue 
("mother's  mark,"  "birth-mark," 
"port-wine  stain");  they  may  be 
elevated  above  the  surface  of  the 
surrounding  skin,or  may  lie  perfectly 
flat  beneath  a  seemingly  normal  epi- 
derm.  They  vary  greatly  in  size. 
Elevation  of  the  affected  part  does 
not  cause  them  to  shrink  or  become 
pale;  nor  does  pressure  blanch  them, 
unless  very  small,  and  then  only 
momentarily.  Usually  they  are 
multiple,  are  most  frequent  on  the 
face  and  neck  (perhaps  branchio- 
genic) ;  tend  to  grow  larger;  and  may 
ulcerate  and  cause  alarming  hemor- 
rhage. Sometimes  they  blend  into 
cavernous  angeiomas,  described  be- 
low. The  pigmented  mole  may  be 
considered  a  variety  of  capillary  nevus:  frequently  it  is  hairy  {ncru.s 
yilosus,  Fig.  239);  usually  remains  of  insignificant  size;  but  occasionally 


Fig.  239. — Nevus  pilosus  (hairy  mole). 
Age  nineteen  years,  growing  slowly 
since  birth.     Episcopal  Hospital. 


HEM  ANGEIOMA    AM)  XEVUS 


2/i 


Fig.  240. — Cavernous  angcioma  of  palm,  hand 
dependent.  See  Fig.  241.  From  a  patient  under 
Dr.  Frazier's  care  in  the  Episcopal  Hospital. 


about  puberty,  or  in  adult  life,  from  trifling  or  no  apparent  cause, 
begins  to  enlarge,  assumes  tumor-like  characteristics,  and  may  develop 
into  or  be  inexplicably  associated  with  melanotic  sarcoma   (p.  130). 

Treatment. — The  treatment  of  capillary  nevi  should  be  undertaken 
within  the  first  few  months  of  life.  The  application  of  carbon  dioxide 
snow  (Pusey,  1907),  for  a  half  minute  or  so,  every  third  or  fourth  day, 
probably  is  the  most  satisfactory  treatment  for  the  port-wine  stains  or 
other  nevi  not  raised  above 
the  surface  of  the  surround- 
ing skin.  This  "cold  caus- 
tic," as  it  has  been  called, 
produces  sloughing  of  the 
diseased  skin,  resulting  in  an 
ulcer  which  heals  with  the 
minimal  amount  of  scarring. 
The  earlier  the  nevus  is 
cured,  the  more  inconspicu- 
ous will  the  scar  be.  Fuming 
nitric  acid  is  more  effectual 
for  raised  capillary  nevi  than 

for  port-wine  stains.  Electrolysis  may  also  be  employed.  Moles  are 
best  treated  by  excision. 

Venous  Nevi. — Venous  nevi  may  occur  in  the  skin  or  subcutaneously, 
in  the  latter  case  usually  being  described  as  cavernous  angeiomas,  their 
structure  resembling  the  cavernous  tissues  of  the  penis.  They  form 
prominent  lobulated  tumors,  easily  compressible,  sometimes  becoming 
tense  when  the  child  cries  or  strains,  emptying  more  or  less  completely 

when  the  affected  part  is  ele- 
vated and  pressure  is  applied, 
and  rapidly  refilling  when  the 
part  is  dependent  (Figs.  240, 
241).  In  the  subcutaneous 
variety  discoloration  of  the 
skin  may  not  be  present.  The 
growths  may  be  circumscribed 
or  diffuse;  the  former  some- 
times is  mistaken  for  a  cold 
abscess;  while  the  diffuse  sub- 
cutaneous cavernous  angeioma 
may  involve  an  entire  extremity 
and  neighboring  portions  of  the 
trunk,  the  entire  limb  being  deformed,  flabby,  pudgy,  and  sponge-like 
to  the  touch  (pseudo-elephantiasis) ;  the  muscles  may  be  wasted,  and 
the  bones  atrophic  (Plate  III).  Muscle  tissue  itself  may  be  invaded 
by  the  angeiomatous  growth.  Similar  angeiomas  occasionally  are 
found  in  the  viscera,  notably  the  liver.  Subcutaneous  cavernous 
angeiomas  usually   are   associated   with  lipomatous  growths  (nevoid 


241. — Cavernous  angeioma  of  palm,  hand 
elevated.     Episcopal  Hospital. 


278  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

lipoma).  They  seldom  cause  hemorrhage  but  may  undergo  throm- 
bosis; ami  formation  of  phleboliths  is  not  uncommon. 

Treatment. — Treatment  consists  in  excision  whenever  this  is 
practicable;  and  in  circumscribed  angeiomas  it  usually  is  not  very 
difficult.  If  excision  be  refused  by  the  parents,  the  surgeon  may 
strangulate  the  tumor  by  ligating  it  in  sections,  leaving  the  pro- 
truding masses  to  be  separated  as  sloughs.  In  cases  where  an 
elastic  tourniquet  or  other  means  of  controlling  the  circulation  can 
be  applied  above  the  seat  of  operation,  Wyeth's  method  (1903) 
may  be  adopted:  this  consists  in  the  repeated  injection  of  boiling 
water  (1  to  2  c.c),  at  intervals  of  several  days;  if  the  water  is  actually 
boiling,  thrombosis  of  the  blood  in  the  angeioma  will  be  immediate 
and  the  clot  so  firm  that  theoretically  no  fear  of  embolism  need 
occur;  but  though  no  such  result  has  been  reported,  so  far  as  I  am 
aware,  the  surgeon  should  be  extremely  cautious  in  employing  this 
method  about  the  face,  where  cerebral  embolism  might  occur,  or  at 
the  root  of  the  neck  or  in  the  axilla,  where  pulmonary  embolism 
might  be  caused.  Diffuse  subcutaneous  cavernous  angeiomas  usually 
can  be  treated  only  by  palliation. 

Arterial  Varix. — Arterial  varix,  known  also  by  the  name  of  Cirsoid 
Aneurysm  (Fig.  242),  and,  when  capillaries  are  involved,  by  the  terms 
Racemose  Aneurysm  and  Aneurysm  by  Anastomosis,  is  an  affection  of 
the  arterial  system  somewhat  analogous  to  varicose  veins,  but  present- 
ing in  many  cases  neoplastic  characteristics  by  which  it  is  allied  to 
angeiomas.  The  arterial  distribution  affected  (most  frequently  on  the 
scalp)  becomes  dilated,  elongated,  tortuous,  and  pouched,  forming  a  vari- 
cose pulsating  tumor  often  of  considerable  size.  It  occurs  usually  in 
early  adult  life,  from  no  well  defined  cause,  though  history  of  trauma 
may  be  obtainable,  and  cases  have  developed  from  congenital  nevi.  The 
tumor  presents  a  characteristic  varicose  appearance,  is  compressible, 
and  may  be  reduced  in  size  by  pressure  on  the  main  afferent  arterial 
trunks;  when  this  pressure  is  removed,  the  tumor  again  increases 
in  size,  by  expansile  pulsation,  perhaps  several  cardiac  impulses 
being  required  before  it  regains  full  size.  Palpation  and  auscultation 
detect  a  systolic  thrill. 

Treatment. — Treatment  is  sought  by  the  patient  for  relief  from  the 
constant  murmur  or  whirr  within  the  tumor,  as  well  as  on  account 
of  the  deformity.  Excision  should  be  done  when  practicable;  some- 
times it  becomes  possible  only  after  preliminary  circumferential 
ligation  of  the  main  arterial  channels  entering  the  tumor  (Fig.  242). 
In  rare  cases  such  ligation  alone  is  sufficient  to  cause  disappearance 
of  the  tumor. 

Aneurysm. — An  aneurysm  is  a  hollow  sac,  filled  with  normal  or 
altered  blood,  in  communication  with  the  lumen  of  an  artery,  and 
developed  wholly  or  in  part  by  progressive  dilatation  of  the  arterial 
walls.  A  traumatic  aneurysm  (p.  265)  properly  is  not  an  aneurysm 
at  all,  but  a  pulsating  hematoma,  since  the  sac  is  formed  not  of  arterial 
wall,  but  by  condensation  of  surrounding  tissues.    Arterial  aneurysms 


w 

< 

Oh 


ANEURYSM 


270 


are  classified  as  true  and  false;  formerly  the  term  "true"  was  applied 
only  to  those  aneurysms  composed  of  all  the  arterial  coats;  but  as 
this  condition  was  found  to  exist  only  in  an  extremely  limited  number 
of  cases  of  very  minute  (miliary)  aneurysms,  it  has  now  been  trans- 
ferred to  all  aneurysms  developed  wholly  or  in  part  by  progressive 
dilatation  of  the  arterial  walls;  while  the  term  " false  aneurysm"  is 
now  applied  only  to  pulsating  hematomas,  etc.  When  a  true 
aneurysm  ruptures  subcutaneously  it  is  better  to  call  it  a  "ruptured 
aneurysm,"  than  a  diffused  or  consecutive  aneurysm  (Fig.  243). 


Fig.  242. — -Cirsoid  aneurysm,  arterial  varix, 
or  aneurysm  by  anastomosis  of  right  ear,  treated 
by  a  series  of  operations  by  the  late  Prof. 
Ashhurst:  1.  Ligation  of  temporal  and  common 
carotid  arteries.  2.  Strangulation  of  growth  by 
multiple  ligatures.  3.  Amputation  of  ear, 
excision  of  tumor,  and  ligation  of  cut  vessels 
separately.     University  Hospital. 


Fig.  243. — Ruptured  aneurysm 
of  left  femoral  artery;  ligation  in 
Scarpa's  triangle  thirteen  years  ago 
for  popliteal  aneurysm.  Rupture 
two  weeks  ago.  Episcopal  Hospital. 


Aneurysm  develops  by  the  gradual  dilatation  of  a  portion  of  the 
arterial  wall  previously  diseased.  At  this  earliest  stage  the  term 
arteriectasis  is  applicable.  As  the  dilatation  proceeds,  the  middle 
tunic  gives  way,  and  the  aneurysmal  wall  is  formed  only  of  the 
adventitia  with  such  clots  as  may  be  deposited  from  the  swirling 
blood  within  the  sac  upon  the  surface  of  the  intima.  The  walls  of  an 
aneurysmal  sac  in  contact  with  circulating  blood  always  are  lined 
by  endothelial  cells,  which  are  proliferated  with  great  readiness  either 
by  extension  from  the  intima  of  the  parent  artery,  or  possibly 
through  the  medium  of  angeioblasts  of  the  vasa  vasorum  (Matas, 
1910).  This  endothelial  lining  may  itself  become  atheromatous  and 
calcareous. 


280 


si  RGBRY  OF  THE  lU.ooD  VASCULAR  SYSTEM 


Aneurysms  are  further  classified  as  to  their  form,  into  (1)  Tubular 
or  Fusiform  (Fig.  244);  (2)  Saccular  (Fig.  245);  and  (3)  Dissecting 
Aneurysms.  Tubular  or  fusiform  aneurysms  are  those  which  involve 
the  entire  circumference  of  an  artery,  and  are  rare  even  in  the  larger 


Fig.  244. — Fusiform  aneurysm. 


Fig.  245. — Saccular  aneurysm,  with 
small  mouth. 


internal  vessels.  Dissecting  aneurysms  are  those  in  which  the  blood 
makes  a  channel  for  itself  between  the  coats  of  the  arterial  wall  for  a 
variable  distance,  and  again  enters  the  arterial  lumen;  they  are  seen 

almost  exclusively  in  the  tho- 
racic or  abdominal  aorta.  The 
saccular  aneurysm,  in  which  the 
dilatation  involves  a  portion 
only  of  the  arterial  circumfer- 
ence, communicates  with  the 
vessel  by  a  comparatively  small 
orifice  called  the  mouth  of  the 
sac;  by  progressive  growth  of  a 
saccular  aneurysm  its  mouth 
may  become  so  lengthened  as 
to  cause  the  aneurysm  to  re- 
semble at  first  glance  one  of 
tubular  or  fusiform  variety, 
especially  on  laying  open  the 
sac,  when  it  will  appear  that 
there  are  two  mouths  present 
(Fig.  246,  B).  Though  aneu- 
rysms usually  are  single,  they 
may  be  multiple;  and  after  cure  by  obliteration  of  one  sac  others  may 
develop  (Fig.  243). 

The  sac  of  an  aneurysm  when  first  formed  contains  fluid  blood; 
the  eddying  and  partial  stagnation  to  which  this  is  constantly  sub- 


Fig.  246. — Saccular  aneu^'sm  with  large 
mouth;  when  opened  it  appears  as  if  there 
were  two  orifices. 


CAUSES  OF  ANEURYSM 


281 


jected  leads  in  time  to  the  deposition  of  fibrinous  dots  on  the  interior 
of  the  sac  wall.  These  are  deposited  in  successive  layers,  constituting 
the  laminated  clot.  This  rarely  becomes  firmly  adherent  in  all  spots 
to  the  sac  wall,  but  is  dissected  loose  by  the  eddying  currents,  thus 
preventing  its  organization.  Should  such  firm  adhesion  and  organiza- 
tion occur,  and  should  concentric  laminations  be  formed  continuously, 
spontaneous  cure  of  the  aneurysm  eventually  might  ensue  by  oblit- 
eration of  its  sac;  but  this  is  extremely  rare. 

Causes. — The  chief  underlying  cause  of  aneurysm  is  precedent 
disease  of  the  vascular  system;  aneurysm  is  but  a  symptom  of  this 
disease;  and  in  the  immense  majority  of  cases  the  vascular  degenera- 
tion is  a  sequel  of  syphilis,1  though  chronic  alcoholism,  even  without 
syphilitic  affection,  is  said  sometimes  to  be  a  cause.  The  immediately 
apparent  cause,  in  most  cases,  is  some  sudden  strain,  exertion,  or 
accident,  which  causes  rup- 
ture of  the  diseased  media  at 
its  most  susceptible  point; 
the  vis  a  tergo  of  the  blood- 
stream then  causes  progres- 
sive dilatation  of  the  artery 
until  a  well  defined  aneurysm 
exists.  Constantly  recurring 
slight  trauma  is  recognized  as 
a  predisposing  cause  in  that  it 
causes  localization  of  arterial 
lesions  where  aneurysms  later 
develop.  Thus  is  explained 
the  preponderance  of  aneu- 
rysm in  the  aortic  arch  and  at 
the  root  of  the  neck,  where 
not  only  is  the  cardiac  im- 
pulse strongest,  but  where 
the  arteries  lie   against  bone 

(vertebra?,  first  rib,  clavicle)  and  where  each  pulsation  tends  to  bruise 
the  arteries  against  this  unyielding  structure;  the  latter  explanation 
is  adduced  by  Barwell  (1882)  to  account  for  the  frequency  of  popliteal 
(Fig.  247)  as  compared  with  brachial  aneurysm. 

Localization. — In  general  terms,  the  aorta  is  affected  in  42  per 
cent.,  the  popliteal  artery  in  24  per  cent.,  the  femoral  in  12  per  cent., 
and  the  carotid,  subclavian,  axillary,  and  innominate  in  about  3 
per  cent,  each — leaving  the  smaller  arteries  of  the  extremities  to  form 
about  10  per  cent,  of  cases  (Crisp,  1847).  Popliteal  aneurysm  forms 
from  55  to  60  per  cent,  of  those  occurring  in  the  limbs  (Matas,  1910). 

Age.— Aneurysm  occurs  mostly  in  patients  in  active  adult  life; 
about  two-thirds  of  cases  are  seen  between  the  ages  of  thirty  and 
fifty   years,   after  arterial   lesions  have  had   a  chance  to   develop, 


Fig.  247. — Popliteal  aneurysm,  right  leg.     Dr. 
Harte's  case.     Pennsylvania  Hospital. 


1  This  was  strenuously  denied  by  Barwell  (1882). 


282  SURGERY  OF  THE  BLOOD  VASCULAR  SYSTEM 

and  while  sudden  strains  are  still  frequent.  Sex:  It  is  seen  in  men 
about  six  or  seven  times  as  frequently  as  in  women,  owing  to  the 
greater  liability  of  the  male  sex  to  atheroma,  and  to  their  more  labori- 
ous life.  Occupations  attended  by  violent  exertion  (porters,  teamsters, 
soldiers,  sailors)  are  regarded  as  p^disposing  to  the  development 
of  aneurysm,  as  are  diseases  of  the  heart  and  kidneys,  chronic,  gout, 
rheumatism,   etc.,   causing  arterial  hypertension  and  calcification. 

Symptoms. — These  usually  are  of  slow  development,  though  occa- 
sionally the  patient  is  aware  that  "something  has  given  way,"  expe- 
riences a  sudden  stinging  pain,  as  the  "coup  de  fouet"  in  rupture 
of  deep  varicose  veins  (p.  274),  and  on  examination  at  once  finds  a 
pulsating  tumor  has  formed.  The  symptoms  of  aneurysm  may  be 
considered  as  those  peculiar  to  the  aneurysm  itself,  and  those  due  to 
its  pressure  on  surrounding  parts.  There  is  present  a  rounded  or 
oval  tumor,  either  apparent  to  the  eye  or  appreciable  to  the  touch; 
it  is  situated  along  the  course  of  an  artery;  it  is  movable  laterally 
but  not  longitudinally  on  the  artery;  and  it  is  somewhat  compressible 
and  elastic  (depending  on  the  amount  of  laminated  clot).  An  aneurysm 
becomes  more  or  less  flaccid  by  pressure  on  the  artery  above,  and 
harder  and  more  tense  by  pressure  on  the  artery  below  the  tumor. 
It  is  covered  by  healthy,  non-adherent  skin,  unless  in  the  last  stages 
when  rupture  is  about  to  occur.  The  affected  part  is  more  or  less 
disabled,  with  muscular  weakness,  paresthesia,  numbness,  or  edema 
(pressure  effects) :  pressure  on  nerves  causes  neuralgic  pain  or  paralysis 
(of  pupil,  of  vocal  cord,  etc.) ;  on  neighboring  veins  causes  varicosities 
and  edema;  on  arteries  (perhaps  the  parent  trunk)  causes  gangrene; 
on  bones  causes  erosion,  with  intense  boring  pain;  on  neighboring 
viscera  (trachea,  esophagus,  bile  ducts,  etc.),  may  cause  serious 
disturbance  in  their  functions.  Aneurysms  pulsate,  synchronously 
with  the  heart:  they  are  not  merely  lifted  by  the  pulsation  of  the 
underlying  artery,  but  as  the  blood  enters  the  sac  and  swirls  around 
in  its  interior  the  sac  walls  dilate,  causing  an  extremely  character- 
istic pulsation  which  is  both  eccentric  and  expansile.  The  degree  of 
aneurysmal  pulsation  depends  on  the  size  of  the  sac  and  of  its  mouth, 
and  on  the  thickness  of  its  walls;  a  small  aneurysm  with  much  thick- 
ened walls  and  a  small  mouth  connecting  writh  the  artery  will  pulsate 
much  less  than  one  which  is  large,  thin  walled,  and  possessed  of  a  large 
mouth.  Pulsation  becomes  more  pronounced  when  the  part  is  depend- 
ent and  when  pressure  is  made  on  the  artery  below  the  sac,  and  may 
almost  disappear  when  the  limb  is  elevated  and  the  artery  occluded 
above  the  sac.  When  pulsation  has  been  made  to  cease  by  the  latter 
method,  application  of  the  hands  over  the  sac  will  enable  the  surgeon 
to  detect  the  entering  blood  when  pressure  is  removed,  and  will 
make  him  appreciate  the  facts  that  the  sac  does  not  always  become 
fully  distended  with  the  first  impulse  from  the  heart,  and  that  the 
pulsation  is  eccentric  and  expansile,  driving  the  hands  not  only 
further  away  from  the  underlying  artery,  but  also  further  apart 
from  each  other.     Pulsation  in  the  artery  below  the  aneurysm  may  be 


blAGNOSIS  OF  ANEURYSM  283 

much  diminished,  as  compared  with  corresponding  pulsation  on  the 
other  side  of  the  body;  this  phenomenon  is  due  to  pressure  on  the 
artery  by  the  overlying  aneurysm ;  while  the  fact  that  the  pulse  below 
the  aneurysm  may  be  delayed  is  explicable  on  mechanical  grounds, 
the  aneurysm  acting  as  the  air-chamber  of  an  hydraulic  ram.  More- 
over, the  arterial  pressure  distal  to  the  aneurysm  is  less  than  in  the 
corresponding  healthy  artery.  Bruit,  which  is  the  peculiar  whirring 
or  rasping  noise  made  by  blood  entering  the  sac,  is  present  with  very 
few  exceptions  (old  thick-walled  aneurysms  almost  full  of  clot);  it 
occurs  during  cardiac  systole,  is  therefore  intermittent,  and  is  loudest 
in  aneurysms  with  large  sac  mouths;  it  may  be  made  to  cease  by 
obliteration  of  the  artery  above  the  aneurysm,  unless  large  collaterals 
empty  into  the  sac;  and  in  aneurysms  of  the  extremities  sometimes 
becomes  louder  when  the  limb  is  elevated.  It  may  be  transmitted 
centrifugally  along  the  diseased  artery.  Its  conduction  by  bone  has 
been  noted" by  Godfrey  (1914).  Thrill  is  to  the  hand  what  bruit  is 
to  the  ear;  but  is  much  less  marked  than  in  arteriovenous  aneurysms. 

Course  and  Termination. — Aneurysm  is  an  incurable  disease,  and 
if  left  to  itself  first  disables  and  then  kills  the  patient  within  com- 
paratively few  years.  Apparent  cure  is  only  temporary,  as  other 
aneurysms  may  develop  or  the  first  recur.  By  proper  treatment, 
however,  symptoms  may  be  relieved,  individual  aneurysms  may  be 
temporarily  cured,  and  the  life  of  the  patient  may  be  prolonged 
indefinitely  (perhaps  fifteen  to  twenty  years)  in  comfort  and  reasonable 
usefulness  (Fig.  243).  Death  finally  comes  slowly  (from  exhaustion, 
inanition,  gangrene,  etc.),  rapidly  (from  pressure  on  trachea  or  larynx, 
on  phrenic  or  pneumogastric  nerve,  from  rupture  and  hemorrhage, 
etc.),  or  suddenly  from  syncope  even  without  rupture. 

Diagnosis. — This  is  made  by  attention  to  the  history  and  physical 
signs.  Arterio-renous  aneurysms  usually  follow  penetrating  wounds; 
other  signs  of  vascular  disease  may  be  wanting;  bruit  is  continuous 
(not  intermittent  except  sometimes  when  the  limb  is  elevated — 
Xelaton),  is  transmitted  both  centrifugally  and  centripetally;  thrill 
is  marked;  and  compression  on  the  afferent  or  efferent  arterial 
trunk  does  not  cause  such  characteristic  changes  in  the  sac.  Other 
vascular  pulsating  tumors  are  less  well  defined  in  outline,  do  not 
present  eccentric  pulsation,  have  little  or  no  bruit,  and  are  not  neces- 
sarily placed  in  the  course  of  a  large  artery.  Other  tumors  may  pulsate 
because  they  overlie  an  artery,  but  the  pulsation  is  neither  expansile 
nor  eccentric,  there  is  neither  bruit  nor  thrill,  and  obliteration  of  the 
afferent  or  efferent  arterial  trunk,  while  it  may  cause  cessation  of 
pulsation,  yet  produces  no  other  change  in  the  tumor.  Non-pulsating 
tumors  may  be  mistaken  for  an  aneurysm  with  contents  clotted;  such 
growths  may  be  movable  longitudinally  as  well  as  laterally,  and 
present  a  different  clinical  history.  An  aneurysm  which  has  become 
diffused  or  inflamed  may  be  mistaken  for  an  abscess  (p.  48),  but 
attention  to  the  history,  and  a  careful  physical  examination  will 
almost  surely  prevent  any  confusion. 


284  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

Treatment.  This  may  be  operative  <>r  non-operative.  Under  the 
hitter  heading  arc  included  hygienic  and  dietetic  measures,  such  as 
alone  are  applicable  to  certain  forms  of  internal  aneurysm.1  All  other 
aneurysms  should  be  operated  upon,  and  nothing  is  gained  by  delay. 
The  end  sought  by  operation  is  to  prevent  blood  from  entering  the 
sac,  thus  allowing  its  obliteration.  Tins  may  be  attempted  in  various 
ways.  The  methods  still  in  most  general  use  endeavor  to  secure 
coagulation  of  the  blood  within  the  sac;  these  may  be  regarded  as 
palliative  operations.  Most  of  them  act  by  retarding  the  current  of 
blood  passing  through  the  parent  artery;  others  act  directly  on  the 
contents  of  the  sac  itself.  They  include  pressure  on  the  afferent 
artery;  compression  of  the  sac  itself  (as  by  flexing  the  knee  for  pop- 
liteal, or  the  hi])  for  inguinal  aneurysm),  ligation  of  the  afferent  artery, 
or  of  the  efferent  artery  or  one  of  its  branches;  injection  of  coagulating 
fluids;  insertion  of  needles  with  irritation  of  the  intima  to  favor  throm- 
bosis; and  introduction  of  metallic  wire  with  electrolysis.  Manipula- 
tion of  the  sac  (Fergusson,  1857),  in  an  effort  to  detach  a  clot  which 
shall  plug  the  efferent  artery,  should  be  mentioned  only  to  be  con- 
demned. Radical  operations  comprise  extirpation  of  the  sac,  with 
suture  or  ligation  of  the  orifice  or  orifices  into  the  parent  artery; 
and  Endo-aneurysmorrhaphy,  which  is  the  best  method  whenever 
applicable. 

Pressure. — The  patient  should  be  confined  to  bed,  and  kept  on 
a  low  diet  with  very  little  fluid;  this  slows  the  circulation  and  favors 
thrombosis  (Tufnell,  1864).  The  pressure  may  be  either  instrumental 
(by  various  forms  of  tourniquets),  or  digital  (Knight,  1844),  which 
is  preferable.  The  afferent  artery  is  compressed  until  the  sac  ceases 
to  pulsate.  Relays  of  assistants  are  required,  each  one  keeping 
up  pressure  for  from  three  to  five  minutes,  being  then  relieved  by 
another  who  compresses  the  artery  above  or  belowT  the  first  point 
of  compression  before  this  is  released  by  the  fingers  of  the  former 
assistant.  In  this  way  the  circulation  of  blood  in  the  sac  is  much 
diminished,  favoring  the  formation  of  a  laminated  coagulum.  Treat- 
ment is  to  be  kept  up  for  from  two  to  four  days,  in  sittings  of  about 
four  hours  once  daily.  After  thirty-six  hours  hope  of  cure  is  much  less, 
and  continuation  of  pressure  dangerous  (sloughing,  etc.).  The  method 
is  most  easily  applicable  to  the  femoral  artery,  for  aneurysm  of  the 
popliteal.  It  should  be  employed  only  when  endo-aneurysmorrhaphy 
or  ligation  are  contraindicated,  as  in  the  very  old  and  feeble,  in  those 
with  serious  visceral  disease,  etc.,  in  whom  the  dangers  of  a  cutting 
operation  are  excessive.  The  method  is  successful  in  perhaps  half 
the  cases  treated.  G.  Fischer  (1869),  found  that  among  188  cases 
of  aneurysm  treated  by  digital  compression,  cure  resulted  in  121 
(over  64  per  cent.),  and  38  of  these  patients  were  cured  in  less  than 
three  days;  of  90  cases  of  popliteal  aneurysm,  72,  or  79  per  cent., 
were  cured  by  digital  compression. 

1  In  all  syphilitic  cases  proper  constitutional  treatment  is  indicated. 


TREATMENT  OF  ANEURYSM 


285 


Ligation. — This  may  be  done  on  the  proximal  side  of  the  aneurysm, 
or  the  distal,  or  on  both  sides. 

Proximal  Ligation. — The  method  of  Hunter  (1785)  consists  in 
applying  a  ligature  some  distance  above  the  aneurysm,  allowing  small 
branches  to  convey  blood  from  above  the  ligature  through  collateral 
circulation,  into  the  sac  of  the  aneurysm  (Fig.  248).  The  advantages 
claimed  for  the  Hunterian  method  are:  (1)  accessibility  of  the  artery; 
(2)  healthier  condition  of  the  arterial  walls;  (3)  gradual  obliteration 
of  the  sac  by  formation  of  laminated  clot.  But  modern  aseptic  oper- 
ating renders  the  artery  easily  accessible  at  any  site,  and  even  if 
the  arterial  wall  be  diseased  close  to  the  sac  (which  is  not  certain), 
application  of  a  ligature  will  strengthen  it,  and  healing  will  occur 


Fig.  218. — Hunter's  method  of  liga- 
tion for  aneurysm:  collateral  circula- 
tion from  above  the  ligature  into  the 
sac. 


Fig.  249. — Anel's  method  of  ligation  for 
aneurysm:  circulation  through  the  sac  com- 
pletely arrested. 


normally.  Objections  to  Hunter's  operations  are:  (1)  the  existence 
of  collateral  circulation  through  the  sac  really  is  unfavorable  to  its 
complete  obliteration;  (2)  interposition  of  two  obstacles  to  the  circu- 
lation (ligature  and  aneurysm)  renders  gangrene  more  likely,  as  does 
the  exclusion  from  the  circulation  of  collaterals  arising  between  the 
ligature  and  the  sac;  (3)  if  the  collateral  circulation  is  successfully 
established  through  the  main  trunk,  recurrence  of  the  aneurysm  is 
likely.  The  method  of  Anel  (1710),  revived  in  1856  by  Broca,  con- 
sists in  the  application  of  a  ligature  close  to  the  sac  (Fig.  249) ;  until 
recent  years  it  was  considered  inferior  to  Hunter's  operation,  but 
aseptic  technique  has  shown  it  to  be  quite  as  safe  and  but  slightly 
more  difficult;  and  its  manifest  advantages  are  that  the  circulation 
through  the   sac  is  completely   suppressed    and   yet   no   additional 


286 


Sl'HUKIiY  OF   THE   BLOOD    VASCULAR  SYSTEM 


obstacle  is  erected  to  the  circulation,  only  one  set  of  anastomosing 
vessels  being  required,  instead  of  two,  as  in  Hunter's  operation. 
Matas,  Delbet,  Weber,  Kohler,  LeConte  and  Stewart  all  prefer  Anel's 
method  to  that  of  Hunter. 

Distal  ligation  also  depends  for  its  curative  effect  on  retardation 
of  the  circulation  within  the  artery,  with  consequent  thrombosis  in 
the  aneurysmal  sac.  Brasdor's  method  ( 179N)  consists  in  ligation  of  the 
main  trunk  immediately  distal  to  the  aneurysm,  no  branch  intervening 
(Hodgson,  1815)  (Fig.  250);  while  the  "new  operation "  of  Wardrop 
(1828)  involves  ligation  of  one  of  the  main  branches  below  the  sac, 
or  of  the  parent  trunk  below  the  origin  of  a  branch  (Fig.  251).    These 


Fig.  250. — Brasdor's  method  of  liga- 
tion for  aneurysm,  applied  for  aneurysm 
of  the  common  carotid  artery  (C).  /, 
innominate;  S,  subclavian  artery. 


Fig.  251. — Wardrop's  method  of  liga- 
tion for  aneurysm,  applied  for  aneurysm 
of  the  innominate  (/).  The  common 
carotid  (C),  and  the  subclavian  (S)  in  its 
third  portion  have  been  ligated,  permit- 
ting slight  circulation  through  the  thy- 
roid axis. 


methods  are  inferior  to  proximal  ligation,  because  less  certain;  but 
are  still  employed  in  places  where  the  proximal  side  of  the  artery  is 
inaccessible,  as  in  Innominate  Aneurysm,  or  large  aneurysms  of  the 
first  part  of  the  Subclavian.  For  innominate  aneurysm  simulta- 
neous ligation  of  the  common  carotid  and  subclavian  arteries  is 
preferred;  this  constitutes  Wardrop's  method,  since  the  subclavian  is 
tied  in  its  third  portion  below  the  origin  of  the  thyroid  axis  and 
vertebral. 

Double  Ligation,  Above  and  Below  the  Sac. — When  this  is  immedi- 
ately followed  by  incision  of  the  aneurysm,  evacuation  of  the  clots, 
and  packing  of  the  sac,  to  control  hemorrhage  from  collaterals  entering 


TREATMENT  OF  ANEURYSM 


287 


the  sac,  it  constitutes  the  operation  of  Antyllus  (third  century,  a.d.); 
if  the  sac  is  opened  first,  the  clots  evacuated,  the  mouth  of  the  sac 
sought  with  the  finger,  and  a  probe  passed  up  and  down  the  parent 
trunk  as  a  guide  to  the  application  of  ligatures  above  and  below 
the  tumor,  it  constitutes  the  "old  operation,"  which  was  temporarily 
revived  by  Syme  (1857). 

At  the  present  time  the  mortality  from  ligation  is  about  8  per  cent. ; 
there  is,  however,  also  the  risk  of  gangrene,  requiring  amputation, 
which  occurs  in  an  additional  8  per  cent,  of  cases  (Delbet,  1907). 
Gangrene  is  due  not  only  to  sudden  arrest  of  the  circulation,  but  also 
to  pressure  on  surrounding  tissues  by  the  thrombosed  sac,  and  some- 
times to  embolism  of  the  artery  below  the  sac.  Even  if  a  patient 
recovers  and  escapes  gangrene,  the  symptoms  from  pressure  (neuritis, 
edema,  etc.),  may  be  not  only  unrelieved  but  even  aggravated  by 
solidification  of  the  sac. 


Fig.  252. — Aneurysm  of  abdominal  aorta.     Death  from  internal  rupture. 
Deaver's  case.     Episcopal  Hospital. 


Dr.  H.  C. 


FlLIPUNCTURE     AND     ELECTROLYSIS;     WlRING     OF     ANEURYSMS. — 

Wiring  was  introduced  by  Moore  (1864),  and  modified  by  Corradi 
(1879)  who  passed  an  electric  current  through  the  wire  coil.  Fine 
gold  or  silver  wire  (No.  28  gauge)  is  used,  being  inserted  through 
a  cannula  which  is  plunged  into  the  aneurysmal  sac;  from  3  to  30 
meters  of  wire  are  introduced;  the  positive  pole  is  attached  to  the 
wire  entering  the  aneurysm  (Hare,  1908),  the  negative  pole  being 
placed  elsewhere  on  the  patient's  body,  and  the  current  (70  to  80 
milliamperes)  is  allowed  to  run  for  nearly  an  hour.  This  method 
may  be  attempted  in  certain  cases  of  internal  aneurysm  in  which 
death  is  imminent  from  rupture,  or  in  which  Tufnell's  treatment 
(p.  284)  (perhaps  combined  with  repeated  venesection — Valsalva's 
method)  fails  to  relieve  urgent  pressure  symptoms,  but  in  which  liga- 
tion or  endo-aneurysmorrhaphy  are  impossible.    Thoracic  aneurysms 


288  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

(aortic  arch,  low  innominate)  are  to  be  localized  by  physical  exami- 
nation and  the  x-ray,  and  the  cannula  plunged  directly  into  the  sac; 
abdominal  aneurysm  is  treated  after  exposing  the  sac  by  laparotomy. 
For  thoracic  aneurysm  no  other  surgical  treatment  is  possible,  except 
in  the  case  of  innominate  aneurysm,  when  simultaneous  double  distal 
ligation  is  preferable.  In  some  cases  of  abdominal  aneurysm  endo- 
aneurysmorrhaphy  can  be  performed,  and  is  preferable  if  temporary 
control  of  the  circulation  can  be  secured.  Matas  (1000)  found  that 
wiring  and  electrolysis  resulted  in  apparent  recovery  in  less  than  20 
per  cent,  of  cases;  in  1910  he  condemns  the  method  as  a  "pure  ex- 
periment, which  is  justified  solely  by  the  imminent  and  unavoidable 
danger  of  death  from  the  progress  of  the  disease  itself."  Eshner 
(1910)  has  analyzed  36  cases  of  aneurysm,  mostly  aortic,  treated  by 
wiring;  9  patients  died  within  ten  days,  22  lived  less  than  one  year, 
and  5  survived  for  periods  ranging  from  fourteen  months  to  over 
eleven  years. 

Extirpation  of  the  Sac,  known  by  the  names  of  Philagrius 
(third  century  A.  I).),  and  Purmann  (1685),  now  finds  an  ardent 
supporter  in  Delbet.  It  removes  the  danger  of  gangrene  due  to  pres- 
sure on  surrounding  parts  by  the  clot-filled  sac,  as  also  the  danger  of 
embolism.  For  its  successful  performance  it  is  necessary  to  secure 
preliminary  control  of  the  circulation,  when  possible  by  application 
of  an  elastic  band  at  the  root  of  the  limb,  or  even  by  direct  clamp- 
ing of  the  afferent  and  efferent  artery.  This  latter  method,  however, 
may  not  prevent  profuse  recurrent  hemorrhage  from  collaterals 
emptying  into  the  sac.  The  vein  should  be  preserved,  and  if  impor- 
tant structures  are  adherent  to  the  sac  that  portion  of  the  sac  should 
be  left  behind.  According  to  Delbet  (1907),  among  86  patients 
treated  by  extirpation  of  the  sac  there  were  no  deaths,  and  gangrene 
followed  in  less  than  3  per  cent. 

Endo-aneurysmorriiaphy,  introduced  by  Matas  in  1888.  After 
controlling  the  circulation,  the  sac  is  opened:  (1)  If  a  fusiform 
aneurysm,  or  a  saccular  aneurysm  with  very  large  mouth  (Fig.  246), 
is  found,  the  sac  is  obliterated  by  a  series  of  fine  chromic  catgut  or 
silk  sutures,  approximating  its  walls,  and  occluding  the  lumen  of  the 
artery  adjacent  to  the  mouth  of  the  sac  (Obliterative  Endo-aneurysmor- 
raphy  (Fig.  253).  (2)  If  a  saccular  aneurysm  with  small  mouth  is 
found,  it  may  be  possible  to  suture  the  margins  of  the  sac  mouth  with- 
out occluding  the  lumen  of  the  parent  artery  (Fig.  254).  Orifices  of 
collaterals  are  then  sutured,  and  the  sac  walls  approximated  as  before 
(Restorative  Endo-aneurysmorrhaphy).  (3)  In  rare  cases  the  form  of  the 
aneurysm  may  be  such  that  it  will  be  possible  to  reconstruct  by  suture 
a  channel  to  represent  the  lumen  of  the  parent  artery,  though  little  or 
no  evidence  of  such  a  channel  exists  when  the  sac  is  opened ;  a  soft 
catheter  may  be  used  as  a  guide  (Fig.  255)  (Reconstructive  Endo- 
aneurysmorrhaphy  or  Ajieurysmoplasty.) 

The  methods  of  Matas  possess  over  ligation  all  the  advantages  of 
extirpation  (less  mortality  and  diminished  risk  of  gangrene)  while  at 


TREATMENT  OF  ANEURYSM 


289 


the  same  time  they  entail  less  trauma  than  extirpation,  and  in  the 
restorative  and  reconstructive  methods  afford  the  possibility  of 
preserving  the  circulation  through  the  parent  artery;  and  even  if 
this  circulation  is  preserved  only  temporarily,  gangrene  is  less  likely 
than  if  the  circulation  is  occluded  immediately  as  in  extirpation. 
If  endo-aneurysmorrhaphy  is  applied  to  cases  of  traumatic  aneurysm, 


Fig.  253. — Obliterative  endo-aneurys- 
morrhaphy. 


Fig.  254. — Restorative  endo-aneurys- 
morrhaphy. 


Fig.  255. — Reconstructive  endo-aneurysmorrhaphy. 

this  should  not  be  until  a  firm-walled  adventitious  sac  has  formed. 
Matas  in  1910  collected  reports'of  110  cases  of  endo-aneurysmorrhaphy 
(including  07  aneurysms  of  the  lower  extremity),  with  only  two 
deaths  (1.8  per  cent.)  attributable  to  the  operation,  and  4  cases  of 
gangrene  (3.0  per  cent.),  3  of  which  were  chargeable  to  complications, 
not  to  the  operation  itself. 


19 


CHAPTER   XI. 

SURGERY  OF  THE  SKIN,  BURS/E,  LYMPHATICS, 
MUSCLES,  TENDONS,  AND  NERVES. 

SURGERY  OF  THE  SKIN. 

Verruca  or  Wart.  This  is  a  localized  hyperplasia  of  the  epidermis, 
and  theoretically  may  be  distinguished  from  a  papilloma,  which, 
as  noted  at  p.  119  is  a  neoplasm.  The  favorite  sites  for  warts  are 
the  hands,  face,  scalp,  and  neck.  They  usually  appear  to  grow  spon- 
taneously, but  in  a  few  cases  a  suspicion  of  contagion  exists;  trauma 
followed  by  moisture  seems  a  predisposing  cause.  They  show  little 
tendency  to  enlarge,  scarcely  ever  become  malignant,  and  occasionally 
disappear  from  no  apparent  cause.  Treatment  is  sought  for  dis- 
figurement, sometimes  for  pain.  Removal  is  accomplished  easily 
by  snipping  off  the  warts  with  scissors,  after  spraying  writh  ethyl 
chloride;  the  base  is  then  cauterized  with  silver  nitrate.  Or  by  apply- 
ing a  drop  or  so  of  fuming  nitric  acid  every  few  days,  the  warts  will 
in  time  shrivel  up  and  fall  off  painlessly.  Recurrence  is  rare  after 
thorough  removal. 

'  J'cnereal  warts  are  those  growing  upon  the  genitals  or  around  the 
anus;  they  are  due  to  irritation  from  uncleanliness,  and  have  no 
necessary  connection  with  any  venereal  disease. 

Callositas  or  Tyloma  is  a  diffuse  hypertrophic  condition  of  the 
skin,  normally  present  to  a  slight  degree  in  the  palms  and  soles, 
and  due  to  intermittent  pressure.  It  becomes  of  surgical  interest 
when  the  hypertrophy  is  so  great  as  to  cause  the  lesion  to  approach 
to  that  of  Clarus  or  Corn:  in  this  lesion  (which  frequently  develops 
in  the  center  of  a  callosity,  or  may  arise  independently,  especially 
on  the  toes)  the  intermittent  pressure  causes  a  pyramidal  shaped 
up-growth  of  epithelial  cells,  which  presses  upon  and  finally  separates 
the  papillae  of  the  skin,  and  causes  exquisite  pain  from  pressure  on 
the  highly  sensitive  nerve-endings  found  in  this  layer.  A  soft  corn 
is  distinguished  from  a  hard  corn  by  the  fact  that  the  former  is  placed 
where  its  surface  is  kept  warm  and  moist,  as  between  the  toes;  while 
the  hard  corn  develops  on  an  exposed  surface.  When  of  long  duration 
a  bursa  may  be  formed  beneath  the  corn,  constituting  a  bunion; 
this  is  most  often  the  case  over  the  metatarso-phalangeal  articulation 
of  the  great  toe,  often  being  combined  wTith  hallux  valgus  (p.  592). 

Treatment. — Treatment  of  corns  consists  in  removal  of  the  cause; 
in  frequent  bathing;  application  of  such  plasters  as  will  relieve  the 
corn  from  pressure;  use  of  salicylic  acid  ointment  (5  to  10  per  cent.); 
(290) 


FURUNCLE  OR  BOIL  291 

paring  the  surface  of  the  corn  (a  frequent  cause  of  cellulitis,  angeio- 
leucitis,  and  sepsis,  if  carelessly  done);  and  sometimes  in  formal 
excision. 

Cornu  Cutaneum  or  Horn,  is  a  rare  affection  of  the  skin,  most 
frequent  in  old  age,  and  about  the  face;  it  may  follow  the  spontaneous 
evacuation  ■  of  a  wen.  Closely 
analogous  to  it  is  the  condition 
of  hypertrophy  of  toe-nails  or 
onychauxis  (Fig.  25G).  Excision 
is  the  best  treatment. 

Keratosis  Senilis. — See  p.  669. 

Ingrowing  Toe-nail. — Ingrowing 

toe-liail,    Seen    almost    exclusively  Fig.  256.— Hypertrophy  of  toe-nail,  or 

in  the  great  toe,  USUally  is  due  to  onychauxis  one  year's  growth  since  the 
...   „     .  °        ,  ,  .   ,  "  ,  nail  was  last  cut  off .     Episcopal  Hospital. 

ill-nttmg  shoes,  which  produce  a 

degree  of  hallux  valgus  (p.  592) :  in  the  early  stages  the  form  of  the 
nail  is  unaltered,  but  the  soft  parts  of  the  pulp  are  crowded  over 
on  its  edge,  and  injudicious  trimming  of  the  nail  down  this  chink 
predisposes  to  ulceration.  Later,  the  edge  of  the  nail  becomes  folded 
under,  and  by  pressure  on  the  pulp,  aggravates  the  condition.  If 
palliative  treatment  be  persisted  in  long  enough,  a  cure  usually  may 
be  produced  by  keeping  the  parts  free  from  pressure,  and  separating 
the  overhanging  skin  from  the  nail  either  by  antiseptic  cotton  stuffed 
into  the  chink,  or  by  drawing  the  skin  aside  by  adhesive  plaster, 
while  the  ulcer  is  treated  by  desiccating  powders  after  cauterizing 
its  base.  The  nail  should  be  cut  square  across  the  top,  and  never 
trimmed  down  at  the  sides.  If  a  rapid  cure  is  demanded,  it  is  best 
to  avulse  the  side  of  the  nail  affected  (both  sides  if  necessary)  by 
splitting  the  nail  down  the  center  with  strong  scissors,  and  grasping 
the  portion  to  be  removed  in  forceps.  Local  anesthesia  is  sufficient. 
As  the  new  nail  grows,  properly  fitting  shoes  must  be  worn  to  prevent 
recurrence. 

Perforating  Ulcer. — Perforating  ulcer,  usually  seen  in  the  sole 
of  the  foot  or  under  the  great  toe,  occurs  in  those  past  middle  life, 
and  is  connected  with  arteriosclerosis  or  trophic  disturbances.  It 
occurs  in  diabetes,  and  in  locomotor  ataxia,  and  probably  is  not  a 
specific  disease,  but  merely  an  evidence  of  tissue  destruction  due 
to  malnutrition.  It  is  not  attended  by  much  pain,  may  follow  slight 
injury,  frost-bite,  etc.,  and  frequently  originates  in  a  small  slough 
in  the  center  of  a  callosity  or  corn.  If  untreated,  the  ulceration 
steadily  progresses,  eating  through  the  foot,  involving  muscles, 
tendon,  and  bone;  is  attended  by  a  stench,  and  in  advanced  stages 
perforates  the  dorsum  of  the  foot.  Under  hygienic  measures,  internal 
administration  of  potassium  iodide,  rest  in  bed,  and  active  local 
treatment  (cleansing,  curetting,  etc.),  temporary  cure  sometimes  is 
obtained. 

Furuncle  or  Boil. — Furuncle  or  boil  is  an  infection  of  a  hair  follicle 
or  sebaceous  gland,  confined  to  the  deeper  layers  of  the  true  skin, 


292  SURGERY  OF  THE  SKIN 

usually  terminating  in  suppuration,  with  the  extrusion  of  a  central 
slough  called  the  core.  The  usual  cause  is  Staphylococcus  aureus, 
which  gains  entrance  through  a  minute  abrasion,  as  from  a  rough 
edged  collar  or  cuff.  Persons  with  disordered  metabolism  (diabetes, 
gout,  nephritis,  scrofula,  eczema,  etc.),  are  especially  predisposed  to 
furunculosis.  The  classical  symptoms  of  inflammation  are  present — 
a  red,  extremely  tender  and  painful  swelling,  attended  by  local  heat, 
in  the  true  skin  and  subcutaneous  tissues.  Boils  vary  much  in  size, 
but  seldom  appear  over  5  cm.  in  diameter;  they  usually  are  multiple, 
sometimes  appearing  in  successive  crops.  Boils  usually  have  a  marked 
tendency  to  point;  those  that  do  not,  are  called  "blind  boils." 

Treatment. — Treatment  includes  such  general  hygienic  and  tonic 
measures  as  will  prevent  a  continuance  or  recurrence  of  the  boils; 
frequent  bathing,  with  the  use  of  alkalies  (sodium  carbonate)  in  the 
bath  and  by  mouth,  is  important.  By  local  treatment  in  the  very 
early  stages  it  sometimes  is  possible  to  abort  a  boil  by  pouring  pure 
ichthyol  over  its  surface,  and  making  a  scab  with  a  film  of  absorbent 
cotton.  In  most  cases,  however,  early  incision,  besides  relieving  pain, 
will  accelerate  extrusion  of  the  slough,  and  prevent  formation  of 
neighboring  boils,  which  are  encouraged  by  poulticing.  After  extract- 
ing the  core,  pure  ichthyol  may  be  poured  into  the  crater  of  the 
furuncle,  or  a  drop  of  carbolic  acid  may  be  introduced  on  a  match- 
stick.  The  surrounding  skin  must  be  kept  clean  and  stimulated  with 
astringent  washes.  In  cases  of  persistent  furunculosis,  benefit  has 
been  derived  from  the  administration  of  autogenous  vaccines.  Skil- 
lern  highly  recommends  sulphurous  acid,  in  doses  of  one  or  two  tea- 
spoonsful  well  diluted;  this  should  be  taken  through  a  tube  and  an 
alkaline  wash  (milk  of  magnesia)  used  afterward  to  preserve  the 
teeth.     Baker's  yeast  has  also  proved  beneficial. 

Carbuncle. — Carbuncle  may  be  regarded  as  an  aggravated  form  of 
boil  (Fig.  257).  The  infection  spreads  more  widely  in  the  subcutaneous 
tissues,  there  is  phlegmonous  inflammation,  and  the  pus  tends  to 
evacuate  itself  through  manifold  orifices,  by  following  the  course  of 
the  columns  adiposes  (Warren,  1881).  Carbuncles  are  most  common 
on  the  nucha,  and  may  extend  almost  from  the  vertex  to  the  shoulder. 
In  the  old,  the  diabetic,  the  subjects  of  advanced  Bright's  disease, 
etc.,  it  forms  a  very  serious  malady,  often  endangering  life.  There 
is  no  clear  limit  to  the  inflammation,  which  usually  is  more  wide- 
spread than  is  apparent  on  the  surface. 

Treatment. — Hygienic  and  constitutional  treatment  is  even  of  more 
value  than  in  furunculosis.  (1)  Small  carbuncles  should  be  treated 
as  boils,  by  early  incision  which  may  be  crucial  if  necessary,  to  facili- 
tate extrusion  of  the  sloughs.  (2)  Medium-sized  carbuncles  should  be 
incised  as  above,  and  then  strapped  with  adhesive  plaster  applied 
concentrically,  until  only  a  small  orifice  is  left  for  the  discharge  of 
pus  (Fig.  258);  this  strapping,  suggested  by  O'Ferral  (1858)  and 
emphasized  as  particularly  valuable  by  J.  Ashhurst,  Jr.  (1869),  acts 
mechanically  by  limiting  the  spread  of  the  phlegmon  by  erecting  an 


TREATMENT  OF  CARBUNCLE 


m 


impassable  barrier  around  the  base,  and  forcing  the  discharge  of 
sloughs  through  the  central  opening;  it  secures  local  rest;  and  also, 
I  believe,  creates  a  certain  de- 
gree of  passive  hyperemia  in 
the  diseased  area,  thus  increas- 
ing the  phagocytic  and  opsonic 
powers  of  the  patient.  The 
strapping  checks  almost  at  once 
the  excessive  pain  caused  by 
the  carbuncle,  and  as  it  may 
be  left  in  place  for  several  days 
at  a  time,  considerably  simpli- 
fies the  treatment.  The  gauze 
which  receives  the  discharge 
through  the  central  opening 
should  be  changed  daily.  The 
diminution  in  size  of  the  car- 
buncle (Fig.  259) ,  evident  when 
the  strapping  is  removed,  is  as 
remarkable  as  it  is  gratifying. 
Seldom  more  than  two  or  at 
most  three  strappings  are  re- 
quired to  convert  an  angry 
volcano  into  a  superficial  ulcer, 
which  readily  heals  under  bland 
ointments.  (3)  Very  large  carbuncles  sometimes  may  be  excised, 
with  benefit:  the  patient  being  anesthetized,  a  circular  incision  is 


Fig.  257. — Carbuncle  of  neck;  duration, 
two  weeks;  incised  a  few  days  ago;  no  im- 
provement.    Episcopal  Hospital. 


Fig.  258.— Carbuncle  of  neck 
strapped  with  adhesive  plaster.  Epis- 
copal Hospital. 


_  Fig.  259. — Carbuncle  of  neck  after  strap- 
ping for  one  week.  Only  a  superficial  ulcer 
remains.     Episcopal  Hospital. 


made  at  the  apparent  outer  border  of  the  carbuncle;  this  incision 
is  carried  down  to  the  deep  fascia  and  muscles,  which  rarely  are 


294 


SIVWKHY   OF   THE  SKIN 


involved,  and  the  entire  sloughing  mass  is  cut  away;  bleeding,  which 
may  be  profuse,  is  checked  by  pressure  with  absorbent  gauze,  which 
may  be  held  in  place  by  sutures,  and  which  should  not  he  removed  for 
four  or  five  days.  Free  stimulation  is  required  after  the  operation, 
and  skin-grafting  may  be  necessary  to  secure  final  cicatrization  (Figs. 
195,  196.) 

Tuberculosis  Cutis.— The  tuberculous  lesions  of  the  skin  of  most 
interest  to  surgeons  are  Lupus  Vulgaris,  Scrofuloderma,  and  Erythema 
Induratum. 


Fig.  200. — Lupus  vulgaris  in  a  girl,  aged 
sixteen  years.  Four  years  ago  the  first 
lymph  node  swelling  appeared  under  the 
chin.  There  followed  tuberculous  lym- 
phangeitis,  which  involved  the  skin.  Two 
years  ago  invasion  of  nasal  mucosa  oc- 
curred, and  this  led  to  involvement  of  the 
skin  over  the  nose.     (Philippson.) 


1 — 

A 

_^yg 

' 

,V-   * 

v| 

'    .':/ 

mk 

_*s~            . 

■ 

m 

A 

zt& 

Fig.  201. — Lupus  vulgaris  of  face,  in 
a  woman,  aged  thirty-eight  years.;  the 
disease  began  twenty-three  years  ago  in 
the  left  cervical  lymph  nodes.  (Phil- 
ippson,) 


Lupus  Vulgaris. — The  tuberculous  lesions  are  seated  in  the  corium, 
and  usually  are  secondary  to  an  insignificant  focus  elsewhere.  The 
disease  occurs  in  young  persons  of  scrofulous  tendencies,  is  most 
frequent  in  the  face,  and  appears  as  one  or  several  minute  red  papules, 
tender  but  not  appreciable  to  touch,  which  on  examination  are  found 
to  be  covered  by  a  thin  pellicle  of  altered  skin,  giving  them,  when 
the  blood  is  pressed  out  by  application  of  a  glass  slide,  a  close  resem- 
blance to  drops  of  apple-jelly.  The  overlying  pellicle  is  soft  and  easily 
punctured,  the  probe  or  scalpel  sinking  for  some  millimeters  into 
the  diseased  area.  These  nodules  may  coalesce,  the  patch  spread- 
ing eccentrically  and  healing  in  the  middle,  and  thus  bearing  some 
resemblance  to  certain  of  the  syphilodermas;  but  the  apple-jelly 
nodules  can  be  seen  in  the  advancing  border  of  the  lupus  patch. 


BR  Y  THE  MA  NO  DOS  I LM 


295 


When  lupus  ulcerates  (lupus  exedens,  as  distinguished  from  simple 
lupus,  or  lupus  non-exedens) ,  the  surrounding  tissues  may  be  widely 
destroyed,  but  the  ulcer  always  remains  superficial;  its  outline  is 
rounded,  its  edges  are  not  indurated,  and  its  course  is  very  slow 
(Figs.  260  and  201). 

Diagnosis. — This  must  be  made  by  careful  examination  to  detect 
the  apple-jelly  nodules,  by  attention  to  the  clinical  history  of  the 
patient,  and  by  exclusion  of  syphilis,  epithelioma,  or  other  rarer 
ulcerations  of  the  skin,  all  of  which  usually  occur  in  older  patients. 
Lupus  erythematosis,  thought  by  many  to  be  due  to  toxins  of  tubercle 
bacilli  lodged  elsewhere  in  the  body,  is  sufficiently  characterized  by 
its  usual  butterfly  outline,  its  persistent  redness,  the  absence  of  the 
apple-jelly  nodules,  and  its  unulcerated  condition. 

Treatment. — The  treatment  includes  constitutional  anti-tuberculous 
measures  (p.  SO),  and  local  remedies.  The  latter,  whenever  possible, 
should  consist  of  excision,  replacing  the  loss  of  tissue  by  skin-grafting 
or  a  plastic  operation  (p.  240).  If  excision  cannot  be  done,  the 
diseased  spots  should  be  gouged  out  with  a  sharp  spoon,  and  the 
cavities  left  treated  with  strong  antiseptics  or  caustics.  Radiography 
is  of  value  in  some  mild  cases,  as  is 
the  use  of  radium,  Finsen  light,  etc. 

Scrofuloderma.  —  Scrofuloderma  is 
the  name  given  to  the  tuberculous 
lesion  of  the  skin  which  results  when 
this  is  invaded  by  a  tuberculous  pro- 
cess in  an  underlying  structure,  as  a 
caseous  lymph  node.  The  condition 
was  referred  to  at  p.  78,  Fig.  .36. 

Erythema  Induratum  or  Bazin's  Dis- 
ease (1855)  is  a  paratuberculous  affec- 
tion usually  of  the  calves  of  the  legs 
of  growing  girls  with  a  scrofulous  taint ; 
it  appears  as  multiple  bluish-red  indu- 
rations, resembling  somewhat  both 
furuncles  and  syphilitic  gummas,  which 
tend  to  soften  and  discharge,  leaving 
indolent  and  very  painful  ulcers.  These 
can  be  made  to  heal  only  by  improv- 
ing the  general  health. 

Erythema  Nodosum. — Erythema  no- 
dosum is  mentioned  merely  to  warn 
the  student  not  to  mistake  its  lesions 
for  contusions  or  abscesses.  The  affec- 
tion usually  is  bilateral,  occurs  in  chil- 
dren, and  in  most  cases  the  shins  are 

affected  (Fig.  262),  though  sometimes  the  lesions  appear  over  the 
subcutaneous  surfaces  of  the  ulnae.  There  is  no  history  of  trauma; 
there  is  more  constitutional  disturbance  than  from  bruises;  and  often 


Fig.  262. — Erythema  nodosum. 
One  week's  duration,  following 
staphylococcic  infection  of  finger 
and  complicated  by  endocarditis. 
Temperature,  100.4°  F.  Episcopal 
Hospital. 


296 


SVRGMRV  OF  THE  SKI  \ 


the  disease  is  one  manifestation  of  an  infection  (perhaps  some  atten- 
uated form  of  tuberculosis)  which  canses  endocarditis,  pleurisy, 
multiple  arthritis,  etc. 

Acne  Rosacea.     Sec  p.  667. 

Epithelioma.     Sec  p,  670. 


Fig.  263.  —  Sebaceous  cyst  of 
scalp;  duration  thirty  years.  Epis- 
copal Hospital. 


Fig.  264. — Sebaceous  cyst  of  ear.    Episcopal 
Eospital. 


Sebaceous  Cyst  (Steatoma,  Wen).— This  is  a  retention  cyst,  due 
to  occlusion  of  the  orifice  of  a  sebaceous  duct.  The  cysts,  which  may  be 
multiple,  occur  mostly  in  the  scalp  and  face  (Figs.  263  and  264); 


Fig.    265. — Sebaceous    cyst    of 
ear  excised.     (See  Fig.  264.) 


Fig.  266. — Dermoid  cyst  of  scalp.     Children's 
Hospital. 


on  the  extremities,  and  especially  below  the  level  of  the  umbilicus  they 
are  extremely  rare.  The  skin  is  adherent  to  the  cyst  at  one  point,  the 
orifice  of  the  duct,  sometimes  visible  as  a  black  dot;  the  cheesy,  malo- 
dorous sebum  usually  can  be  squeezed  out,  after  inserting  a  probe  into 


WOUNDS  OF  BURS.K 


297 


the  duct.  These  cysts  frequently  become  inflamed  and  suppurate; 
when  they  discharge  spontaneously,  a  bleeding  fungous  mass  protrudes 
which  may  be  mistaken  for  a  malignant  papilloma;  and  carcinomatous 
changes  are  not  unknown  (p.  597).  If  the  discharge  of  sebum  crusts 
on  the  surface,  a  cutaneous  horn  (p.  291)  may  develop.  Some  seques- 
tration cysts  (p.  131)  are  clinically  indistinguishable  from  sebaceous 
cysts  (Fig.  266). 

Treatment. — Wens  are  removed  easily,  under  local  anesthesia, 
by  dividing  the  overlying  skin  and  dissecting  the  unruptured  sac 
from  the  subcutaneous  tissues,  to  which  its  adhesions  are  light. 
Recurrence  is  frequent  unless  all  the  cyst  wall  is  removed.  If  of 
large  size  some  of  the  overlying  skin  may  be  excised. 

Pilo-nidal  Cysts  and  Fistulse. — These  are  a  form  of  sequestration 
cysts,  mentioned  at  p.  131.  They  occur  most  often  in  the  region  of 
the  anus,  and  may  be  congenital  or  acquired.  According  to  Hodges 
(1880)  only  the  sinus  is  congenital,  and  the  hairs  work  their  way  in 
during  post-natal  life,  finally  occluding  the  orifice  of  the  sinus  and 
forming  a  cyst.  Suppuration  is  frequent.  Excision  is  the  proper 
treatment  (Klemm,  1909). 

INJURIES  AND  DISEASES  OF  BURS^I. 

Wounds  of  Bursse. — If  the  bursa  opened  communicates  with  a 
joint,  serious  consequences  may  follow;  and  as,  in  the  case  of  a  bursa 
which  sometimes  communicates  with  a  joint,  the  fact  of  its  non- 
communication can  never  be  known  a  priori,  all  such  cases  should 


Fig.  267. — Prepatellar  bursitis;  two 
months'  duration;  subacute  onset.  Epis- 
copal Hospital. 


Fig.  26S.  —  Olecranon  bursitis,  two 
months'  duration;  no  acute  trauma.  Epis- 
copal Hospital. 


be  treated  as  if  a  joint  were  involved  (p.  423).  If  the  wound  is 
a  puncture,  it  should  be  enlarged,  after  suitably  cleansing  the  part; 
and  foreign  matter  should  be  extracted,  the  bursa  drained,  and  local 
and  constitutional  rest  provided.  If  no  infection  follows,  the  bursa 
will  heal  with  partial  or  complete  obliteration  of  its  cavity.  If  suppu- 
ration occurs,  antiseptic  applications  or  irrigations  should  be  adopted  so 


298 


IXJl  /,'//<>    AM)   hlSKASKS  OF  Blh'S.F 


soon  as  it  is  evident  that  no  progress  toward  healing  is  being  made 
merely  by  drainage.  Finally,  the  bursa  may  be  excised  it'  continuance 
in  conservative  treatment  is  ineffectual. 

Bursitis.  Bursitis,  or  inflammation  of  a  bursa,  usually  follows 
contusions,  and  may  be  acute  or  chronic.  Acute  bursitis  follows 
slight  continuous,  or  frequently  intermitted  trauma,  as  in  the  retro- 
calcaneal  bursa  (Achillobursitis  or  Albert's  disease,   1893),  or  in  the 

olecranon  bursa  in  those  confined  to  bed, 
with  gouty  tendency.  Relief  of  pressure, 
evaporating  lotions,  and  rest,  usually  cause 
subsidence  of  the  inflammation  in  a  few 
hours.  If  suppuration  occurs,  early  free 
incision  should  be  made.  Chronic  Bur- 
sitis, which  follows  slight  but  continually 
repeated  trauma,  may  be  a  sequel  of 
acute  bursitis  or  may  be  chronic  from 
the  start.  The  bursse  most  often  af- 
fected are:  (1)  Prepatellar  ("Housemaid's 
Knee,"  Fig.  267);  (2)  Olecranon  ("Miner's 
Elbow,"  Fig.  268);  or  (3)  the  bursa  over 
the  Tuber  Ischii   ("Weaver's  Bottom"). 


Fig.  269.  —  Inflammation  of 
bursa  beneath  tendo  patella?, 
bulging  on  inner  side  of  tendon. 
Acute  onset  three  days  ago,  from 
acute  flexion  of  knee.  "Dis- 
persed" by  a  blow.  Episcopal 
Hospital. 


Fig.  270. — Ganglion  in  bursa  of  biceps  brachii  at 
insertion.    Episcopal  Hospital. 


Other  bursa?  sometimes  affected  are:  (4)  Subacromial  Bursa  (see 
Periarthritis,  p.  507);  (5)  that  beneath  the  Tendo  Patellae  (Fig. 
269) ;  (6)  those  over  the  Femoral  Condyles  (see  Ganglion  of  Popliteal 
Space,  p.  314);  (7)  Subgluteal  Bursa;  (8)  that  over  the  head  of  the 
first  metatarsal  bone  (see  Bunion,  p.  290,  and  Hallux  Valgus,  p.  592) ; 
(9)  between  the  tendon  of  the  Biceps  and  tuberosity  of  the  Radius 
(Fig.  270).  By  coagulation  of  the  effused  fluid,  solid  enlargement  of 
a  bursa  may  occur. 

Treatment. — Treatment  of  chronic  bursitis  consists  in  removal 
of  the  cause,  application  of  sorbefacient  ointments,  painting  with 
tincture  of  iodin,  etc.;  and,  these  failing,  in  tapping  and  injection 
of  2  per  cent,  formalin-glycerin  solution  or  dilute  alcohol  (never  when 
joint-communication  may  exist),  in  incision  and  drainage  (when 
healing  will  occur  by  obliteration  of  the  sac),  or  in  excision  which 
is  best  in  most  cases,  especially  those  of  long  duration  with  thick 
sac  walls. 


LYMPHADENITIS  299 

INJURIES  AND  DISEASES  OF  THE  LYMPHATICS. 

Wounds. — Wounds  of  the  lymphatics  are  of  little  moment  except 
when  the  thoracic  duct  is  injured,  as  it  may  be  in  operations  on  the 
neck.  If  this  accident  is  discovered  when  the  wound  is  inflicted  (by 
a  discharge  of  milky  fluid  in  the  wound — lymphorrhea),  an  attempt 
should  be  made  to  apply  a  lateral  suture.  If  this  is  impossible, 
both  ends  of  the  duct  should  be  ligated;  and  this  failing,  the  wound 
should  be  tamponed.  If  the  injury  is  not  discovered  at  the  time  of 
operation,  it  soon  makes  itself  manifest  by  a  discharge  of  chyle  from 
the  wound,  and  by  rapid  and  progressive  emaciation.  There  should 
be  no  delay  in  reopening  the  wound  and  suturing  or  ligating  the 
duct.  Fredet  (1910)  collected  58  cases  of  injury  to  the  thoracic 
duct,  with  five  deaths. 

Lymphorrhea. — Lymphorrhea  may  also  occur  from  wounds  of 
lymphangiectases  (p.  300). 

Chylothorax  and  Chylous  Ascites  occasionally  follow  rupture  from 
contusion  of  the  thoracic  or  abdominal  portions  of  the  thoracic  duct. 
Repeated  tapping  of  the  thoracic  or  abdominal  fluid  has  resulted  in 
cure  in  a  few  cases.  Certain  chylous  cysts  of  the  mesentery  (Chapter 
XXIII)  have  a  similar  origin.  Chyluria  may  result  from  communica- 
tion with  the  urinary  tract. 

Lymphangeitis  or  Angeioleucitis,  inflammation  of  lymphatic  vessels, 
usually  is  due  to  spread  of  infection  from  a  wound.  It  is  seen  most 
often  on  the  extremities,  but  I  have  seen  it  on  the  abdomen  as  a  result 
of  omphalitis.  There  are  one  or  several  flame  red,  irregular  streaks 
running  from  the  site  of  infection  (felon,  lacerated  wound,  etc.)  up 
to  the  axillary  or  inguinal  lymph  nodes;  these  streaks  coalesce  here 
and  there  to  form  broader  red  bands,  and  may  again  separate  before 
reaching  their  terminus  (Plate  I,  Fig.  1,  p.  66).  They  are  not  particu- 
larly painful  or  tender,  seldom  are  palpable,  and  are  redder  and  less  reg- 
ular in  their  course  than  veins  in  cases  of  phlebitis  (p.  270).  There 
is  considerable  fever,  chills  may  occur,  and  lymphadenitis  usually 
co-exists.  Treatment  consists  in  cure  of  the  focus  of  infection;  in 
local  rest  by  splints,  confinement  to  bed,  etc.,  and  in  applications  of 
silver  nitrate,  dilute  iodin,  ichthyol,  etc.,  along  the  course  of  the 
inflamed  lymphatics.  Suppuration  frequently  occurs  in  the  lymph 
nodes,  but  seldom  along  the  lymph  vessels. 

Lymphadenitis. — Lymphadenitis,  or  simply  "adenitis,"  occurs  as 
an  incident  in  cases  of  lymphangeitis,  but  may  also  occur  when  no 
evidences  of  superficial  lymphangeitis  exist.  Thus  femoral  or  inguinal 
adenitis  (bubo)  frequently  follows  a  blister  of  the  foot,  or  venereal  or 
other  infection  of  the  genitals,  when  no  sign  of  lymphangeitis  can  be 
detected  (Fig.  271).  Epitrochlear  or  axillary  adenitis  may  arise  from 
a  slight  abrasion  or  punctured  wound  of  the  hand  which  healed  before 
the  secondary  lesion  was  noticed.  The  symptoms  are  those  usual 
in  inflammation,  and  the  tender,  enlarged  lymph  nodes  are  distinctly 
palpable.    Suppuration  is  not  unusual.     Secondary  invasion  by  specific 


300 


l\.n  /,•//•>  AND  DISEASES  OF  THE  LYMPHATICS 


microbes  (chancroidal,  tuberculous)  may  occur,  and  somewhal  changes 
the  character  of  the  lesion.  Any  lymphadenh  is  which  assume-  a  sub- 
acute or  chronic  course  is  liable  to  infection 
with  tubercle  bacilli  through  the  blood- 
stream. This  is  especially  true  of  cervical 
adenitis  (p.  725).  Chancroidal  bubo  is 
discussed  in  Chapter  XXVI. 

Treatment.  Treatment  of  adenitis  im- 
plies cure  of  the  source  of  infection;  anti- 
phlogistic applications  to  the  seat  of 
adenitis;  early  incision  in  case  of  suppura- 
tion; and  finally  formal  excision  of  the 
diseased  mass  of  lymph  nodes  if  the  re- 
sulting sinus  fails  to  close  under  conserva- 
tive treatment  or  if  the  lymph  nodes 
remain  enlarged  and  tender  without  the 
occurrence  of  suppuration. 

Lymphangiectasis.  —  Lymphangiectasis, 
or  dilatation  of  lymph  channels,  results 
from  obstruction  to  the  flow  of  lymph. 
This  may  be  due  to  external  pressure  (as 
from  tumors  or  cicatrices);  to  operative 
removal  of  the  nodes  draining  the  part; 
or  it  may  be  caused  by  chronic  lymphan- 
geitis,  causing  obliteration  of  the  main 
lymph  vessels,  often  following  repeated 
attacks  of  erysipelas,  etc.  It  is  much 
rarer  as  a  consequence  of  external  pressure  than  is  phlebectasis 
(p.  274),  because  the  lymphatic  collateral  circulation  as  much  freer. 
Sometimes  it  affects  the  spermatic  cord,  constituting  a  lymphatic 
varicocele.  When  a  distinctly  localized  swelling  is  formed,  it  is  known 
as  lymphangeioma;  this  occurs  oftenest  as  a  congenital  condition 
in  the  face  or  neck,  but  may  develop  in  adult  life  (Fig.  272). 
It  forms  a  soft  fluctuating  swelling,  covered  by  healthy  skin. 
Excision  is  the  proper  treatment,  but  if  complete  extirpation  is  im- 
possible, a  partial  operation  entails  great  risk  of  lymphorrhagia, 
with  malnutrition;  in  such  cases  galvano-puncture  may  be  tried. 
Macromelia,  or  giant  growth  of  a  part,  usually  is  a  lymphangei- 
omatous  condition;  one  finger,  the  lips,  the  tongue,  etc.,  may  be 
affected. 

Lymphedema  results  from  lymphangiectasis  and  consists  of  thick- 
ening of  the  subcutaneous  tissues  from  the  effused  fluid  with  cellular 
reaction.  The  superficial  and  deep  lymphatics  have  no  communi- 
cation except  through  the  lymph  nodes;  at  all  other  sites  the  deep 
fascia  is  an  impermeable  barrier  (Kondoleon,  1912).  The  edema  thus 
is  limited  by  the  ski  i  abow  and  deep  fascia  beneath.  It  occurs 
principally  in  the  lower  extremity  (Fig.  273),  often  associated  with 
chronic  ulcer  (Fig.  274),  or  in  the  upper  extremity  following  ablation 


Fig.  271. — Femoral  lymph- 
adenitis; duration,  two  days; 
from  infected  wound  of  left  foot 
two  weeks  ago.  Episcopal 
Hospital. 


/.  YMPHAXGIECTASIS 


301 


of  mammary  carcinoma  and  axillary  lymphatics  (Fig.  824).      Heredi- 
tary persistent  edema  of  the  legs  (Fig.  275),  which  has  been  studied  by 


Fig.  272. — Lymphangioma  of  right 
foot,  aged  seventy-five  years;  duration, 
seven  years.   Orthopaedic  Hospital. 


i 

1 

f[ 

f 

Fi( 


273. — Lymphedema;  duration,  one 
year.    Episcopal  Hospital. 


Jopson  (1898),  is  believed  by  Hope  and  French  (1908)  to  be  a  vascular 
neurosis,  causing  hard  edema,  which  terminates  abruptly  at  the  knee 
or  groin,  there  being  no  evidence  of 
venous  or  lymphatic  obstruction;  but 
the  result  is  very  like  lymphedema.  If 
palliative  treatment  (bandaging,  mas- 
sage, administration  of  thyroid  extract, 
etc.)  fails,  various  operative  measures 
may  be  undertaken.  Excision  of  strips 
of  deep  fascia  (7  by  15  cm.)  was 
successful  in  7  patients  under  the  care 
of  Kondoleon.  Lymphangeioplasty 
(Handley,  1908)  consists  in  inserting 
long  strands  of  silk  in  the  subcuta- 
neous tissues  from  the  hand  or  foot 
to  the  axilla  or  groin;  these  act  as 
capillary  drains  and  rapidly  reduce  the 
edema.  But  many  recurrences  have 
been  reported.  Lanz  (1911)  drilled 
holes  into  the  medulla  of  the  femur 
and  inserted  into  them  strips  of  fascia 
lata  still  attached  by  one  end,  thus 

creating  new  channels  of  drainage  through  the  marrow  cavity 
tation  is  the  last  resort. 


Fig.  274.  —  Lymphedema  with 
decubitus  in  a  woman  twenty-three 
years  of  age;  unable  to  stand.  Ulcer 
healed  and  patient  walking  after  tak- 
ing thyroid  extract  for  two  weeks. 
Episcopal  Hospital. 


Ampu- 


302 


INJURIES  AND  DISEASES  OF  THE  LYMPHATICS 


Elephantiasis  Arabum  is  a  form  of  lymphedema  due  to  obstruction 
of  lymph  channels  by  filaria  sanguinis  hominis,  the  disease  being 
called  filariasis.  The  parasite  is  transferred  from  patient  to  patient 
through  a  mosquito  as  intermediary  host.  In  the  patient  the  half 
grown  parasites  lodge  in  the  peripheral  lymphatics,  there  become 
mature  and  produce  offspring.  The  embryos  enter  the  blood-stream, 
but  appear  in  the  peripheral  circulation  only  at  night;  when  the 
patient  is  at  rest  they  are  readily  abstracted  thence  by  the  mosquito. 
Elephantiasis  affects  the  lower  extremities  and  the  scrotum  more 
often  than  other  parts  of  the  body.    It  is  rare  in  this  country,  except 


Fig.  275. — Persistent  hereditary  edema  af- 
fecting two  brothers.  (See  Fig.  276.)  (Dr. 
Jopson's  cases).    Children's  Hospital. 


Fig.  276. — Persistent  hereditary 
edema,  in  two  brothers.  (See  Fig. 
275.)  (Dr.  Jopson's  cases).  Chil- 
dren's Hospital. 


in  persons  recently  returned  from  the  tropics.  Treatment:  Palliation 
is  secured  by  support,  bandaging,  etc.,  but  excision  usually  is  indi- 
cated.   Amputation  may  be  necessary. 

Hodgkin's  Disease  (1832)  (Malignant  Lymphoma,  Lymphomatosis, 
etc.).  This,  according  to  Adami,  is  a  condition  01  the  lymph  nodes 
comparable  to  keloid  in  the  skin — "an  excessive  overgrowth  of  the 
lymphoid  stroma  secondary  to  a  minimal  or  unrecognized  irritation." 
The  disease  was  referred  to  in  the  chapter  on  Tumors  (p.  115);  it 
appears  to  occupy  a  place  midway  between  the  infectious  granu- 
lomas and  pure  tumors.     Yates  and  Bunting  (1915)  believe  it  is  an 


HODGKIN'S  DISEASE 


303 


infectious  granuloma,  developing  first  in  related  lymph  nodes  (espe- 
cially those  of  neck,  groin,  axilla)  from  some  slight  lesion  of  skin  or 
mucous  membrane.  It  presents  what  some  consider  a  typical  histo- 
logical picture — endothelial  proliferation,  giant  and  eosinophile  cells. 
It  is  permissible  to  excise  some  tissue  for  diagnosis.  Sometimes  it 
resembles  tuberculosis  of  lymph  nodes  (tuberculous  infection  may 
be  secondary),  at  others  it  approaches  lymphosarcoma  in  type.  A 
number  of  observers  have  found  in  the  affected  lymph  nodes  a  Gram- 
staining,  non-acid-fast,  polymorphous  diphtheroid  bacillus. 

Symptoms  and  Treatment. — It  affects  young  adults,  especially  males, 
the  cervical  lymph  nodes  usually,  those  of  groin  or  axilla  rarely,  being 
first  enlarged  (Fig.  277) .  The  axillary,  inguinal, 
abdominal,  and  thoracic  nodes  are  subsequently 
affected;  even  the  spleen  becomes  enlarged. 
The  masses  are  not  inflammatory  in  character; 
do  not  adhere  to  the  skin;  the  individual 
nodes  remain  discrete  a  long  time;  suppuration 
is  unknown;  enlargement  is  progressive, 
though  temporary  remissions  may  occur. 
Severe  anemia  accompanies  the  disease;  the 
patient  is  feverish,  listless,  becomes  dyspneic, 
weak,  emaciated,  and  dropsical.  There  is  no 
hyperleukocytosis  in  early  cases,  the  only 
marked  blood  change  being  reduction  in  the 
amount  of  hemoglobin.1  The  most  distressing 
symptoms  are  those  due  to  pressure  of  the 
immense  masses  in  the  neck  and  mediasti- 
num, and  it  is  usually  for  such  effects  only  that  surgical  treatment, 
consisting  in  excision,  has  been  recommended.  Yates,  however, 
advocates  early  block  dissection,  as  for  cancer,  of  the  primary  group 
of  lymph  nodes  affected.  After  the  removal  of  the  main  bulk  of 
diseased  tissue,  he  finds  that  .r-ray  treatment  may  improve  other 
groups  of  enlarged  nodes;  and  he  reports  some  patients  apparently 
well  after  intervals  of  five  years.  Burnham  (1919)  finds  radium  very 
useful,  even  without  operation.  Treatment  by  vaccines  made  from 
the  bacillus  mentioned  above  has  been  attempted  by  Billings  and 
Rosenow  (1913)  with  rather  encouraging  results.  Untreated,  and  in 
many  cases  in  spite  of  all  treatment,  the  disease  tends  toward  a  fatal 
termination,  its  duration  being  measured  by  months  rather  than  by 
years. 


Fig.  277.  —  Hodgkin's 
disease  affecting  the  neck 
and  both  axillse.  (Dr.  J. 
Ashhurst,  Jr.'s  case.)  Uni- 
versity Hospital. 


1  Yates  and  Bunting,  however,  recognize  typical  blood  changes:  always  an 
increase  in  the  number  of  blood  platelets  (unless  exhaustion  of  bone  marrow 
occurs),  with  forms  which  are  abnormally  large;  and  either  a  relative  or  absolute 
increase  in  the  so-called  transitional  cells.  In  advanced  cases  they  assert  the 
leukocytes  may  be  increased  even  to  100,000;  and  that  the  transitionals  always 
outnumber  the  lymphocytes,  being  more  than  8  per  cent,  of  the  differential  count 
except  in  cases  of  very  high  leukocytosis. 


304  INJURIES  AND  DISEASES  OF  MUSCLES 

Lymphosarcoma. — Lymphosarcoma  was  referred  to  at  p.  11"). 
Theoretically  we  may  distinguish  (1)  True  Lymphosarcoma,  from 
sarcomatous  proliferation  of  the  connective  tissue  cells  of  a  lymph 
node;  (2)  Malignant  Lymphoma,  from  malignant  proliferation  of 
lymphocytes  in  the  lymph  node;  and  (3)  Lymphoma  Sarcomatodes, 
indicating  secondary  (anaplastic)  sarcomatous  change  in  the  lympho- 
cytes of  a  benign  lymphoma  (p.  115).  The  distinction  is  difficult 
histologically  and  impossible  clinically. 

The  disease  may  occur  in  the  mediastinum  or  neck;  tends  to  spread 
locally,  to  ulcerate,  and  to  produce  death  by  pressure,  hemorrhage1 
or  cachexia;  internal  metastases  (liver,  lung)  may  occur  early,  due  to 
the  invasion  of  veins  by  the  original  tumor;  involvement  of  other 
groups  of  superficial  lymph  nodes  is  very  unusual. 

Diagnosis. — Diagnosis  is  difficult:  it  may  be  distinguished  from 
Hodgkin's  disease  by  the  rapid  growth  (weeks  rather  than  months), 
the  unilateral  rather  than  bilateral  involvement,  the  tendency  to 
ulceration,  and  the  persistently  local  character  until  the  last  stages; 
from  tuberculosis  of  lymph  nodes  by  the  greater  firmness,  and  absence 
of  caseation  and  suppuration  even  when  ulceration  has  occurred. 
Treatment  is  of  little  avail;  excision  should  be  attempted,  especially 
to  relieve  pressure  effects;  but  complete  removal  is  difficult  and  recur- 
rence usually  is  prompt.  Radium  and  .r-ray  therapy  find  here  their 
legitimate  field. 

Carcinoma  of  Lymph  Nodes  is  secondary  to  a  primary  focus  else- 
where.  In  the  neck,  it  should  not  be  confused  with  a  branchiogenic 
carcinoma  (p.  731),  which  is  primary  in  epithelial  rests  which  may 
be  scattered  among  lymph  nodes  and  may  invade  them  very  early. 
So-called  primary  carcinoma  of  lymph  nodes  really  is  an  endothelioma. 

INJURIES  AND  DISEASES  OF  MUSCLES. 

Wounds  of  Muscles  —Little  more  need  be  said  of  these  than  what 
is  contained  in  the  discussion  of  wounds  in  general  (p.  102).  Sutures 
do  not  hold  very  firmly  in  muscular  tissue  alone;  therefore  mattress 
sutures  are  used,  and  in  the  case  of  transverse  division  of  the  muscular 
fibers  the  overlying  fascia  (muscular  sheath)  is  included  in  the  sutures 
when  possible.  The  cicatrix  formed  in  a  muscle  may  somewhat 
impair  its  contractility,  but  the  disability  is  slight  unless  the  scar 
is  adherent  to  the  skin  or  bone  or  unless  the  motor  nerve  has  been 
severed. 

The  sheath  of  a  muscle  may  be  ruptured  by  external  injury  (con- 
tusion) or  possibly  by  violent  muscular  contraction;  the  belly  of  the 
muscle,  when  relaxed,  may  then  protrude  through  the  rupture,  con- 
stituting a  muscular  hernia.  Such  a  protrusion  is  made  to  disappear 
by  passive  elongation  of  the  muscle  or  by  its  active  contraction  (Fara- 
beuf,    ISM  i.     Some  forms  of  ventral  hernia   (Fig.  857)  are  of  this 

1  The  hemorrhagic  sloughing  ulceration  constitutes  one  form  of  the  Fungus 
Hematodes  of  the  older  writers. 


MYOSITIS 


305 


nature.  The  diagnosis  is  based  on  the  history  of  trauma  and  the 
appearance  of  an  abnormal  protrusion  only  when  the  muscle  is  relaxed; 
sometimes  when  the  muscle  is  relaxed,  the  aperture  in  its  sheath  is 

palpable.  Most  cases  so  diag- 
nosed are  some  other  condition, 
such  as  rupture  of  the  muscle 
as  well  as  of  its  sheath  (see  be- 
low) or  the  presence  of  an  intra- 
muscular lipoma.  In  both  these 
cases,  contraction  of  the  muscles 
produces  a  swelling,  while  its 
relaxation    causes    the    swelling 


.© 


Fig.  278. — Diagram  representing  a  cube  of 
extensive  rupture  of  the  abdominal  wall  com- 
plicated by  fracture  of  the  iliac  crest.  The 
shaded  area  indicates  the  extent  of  the  re- 
sulting hematoma.  (See  Fig.  279.)  Episcopal 
Hospital. 


Fig.  279. — Rupture  of  abdominal 
wall  and  fracture  of  pelvis,  after  opera- 
tion. (See  Fig.  278.)  Episcopal  Hos- 
pital. 


almost  if  not  altogether  to  disappear.  Treatment  consists  in  suture 
of  the  rent. 

Rupture  of  a  Muscle,  much  rarer  than  rupture  of  its  tendon  (p.  809), 
usually  results  from  violent  muscular  contraction,  without  external 
injury.  The  abdominal  muscles,  however,  may  be  ruptured  sub- 
cutaneously  by  a  crushing  accident  (Fig.  278).  The  lesion  is  sub- 
cutaneous, and  when  due  to  muscular  action  alone  occurs  oftenest 
in  patients  with  rheumatic  or  fibrotic  tendencies.  When  a  long 
muscle,  such  as  the  biceps  brachii  or  quadriceps  femoris,  is  affected, 
there  is  a  distinct  hollow  perceptible  between  the  retracted  ends, 
and  this  becomes  more  evident  during  voluntary  contraction.  Func- 
tional impairment  may  be  marked. 

Treatment. — Treatment  consists  in  suture  of  the  muscle  and  its 
sheath. 

Myositis. — Myositis,  or  inflammation  of  a  muscle,  is  frequent  in 
rheumatism  and  as  the  result  of  contusions.  Septic  myositis  occurs 
20 


300 


INJURIES  AND  DISEASES  OF  MUSCLES 


becomes  swollen, 
of  almost  wooden 
Suppuration  is  un- 


Fig.  280.— Myositis  of  left 
quadriceps  femoris;  unknown 
cause;  duration,  five  weeks. 
Aged  fifty-three  years.  Epis- 
copal Hospital. 


by   invasion  from  a  neighboring  focus  (bone,  joint,    lymph   node), 
or  as   a  metastatic  infection  in  pneumonia,  typhoid  fever,  etc.     In 

such  cases  the  ordinary  symptoms  of 
inflammation  are  present,  and  suppura- 
tion, with  extrusion  of  sloughs  (necrotic 
masses,  p.  58),  is  the  rule.  In  traumatic 
myositis  the  muscle 
painful,  tender,  and 
hardness  (Fig.  280). 
usual. 

Treatment. — Treatment  comprises  rest, 
with  application  of  sorbefacient  ointments; 
anti-rheumatic  remedies  internally  may 
relieve  pain.  Acupuncture  and  wet  cup- 
ping may  be  tried.  Massage  is  beneficial 
when  acute  symptoms  subside.  Meta- 
static abscesses  in  muscle  require  prompt 
evacuation. 

Myositis  Ossificans  occurs  in  two  forms, 
the  stationary  and  the  progressive. 

1.  Myositis  Ossificans  Traumatica,  the 
stationary  form,  is  due  to  injury,  usually 
following  sprains,  luxations,  repeated  slight 
contusions,  etc.  If  small  fragments  of  periosteum  have  been  detached, 
it  is  possible  that  these  may  cause  bony  growrth  in  the  muscles  or 
tendons  surrounding  a  joint;  but  it  is  held  by  some  that  the  muscle 
cells  themselves  or  those  of  the  perimysium  may  produce  bone.  The 
disease  occurs  in  the  adductor  muscle  of  the  thigh  ("rider's  bone"), 
in  the  deltoid  from  shouldering  a  musket,  in  the  brachialis  anticus 
(Fig.  281)  following  dislocation  of  the  elbow,  in  the  tendo  Achillis 
following  sprains,  etc.  The  diagnosis  rests  on  a  history  of  injury,  and 
on  the  existence  of  a  localized,  tender,  hard,  more  or  less  movable  mass 
in  the  body  of  a  muscle  or  tendon.  The  x-ray  usually  is  necessary 
to  confirm  the  diagnosis.  Proper  treatment  is  excision  of  the  bony 
mass,  unless  this  shows  a  tendency  to  retrogress  spontaneously  when 
the  part  is  put  at  rest. 

2.  Myositis  Ossificans  Progressiva  is  an  obscure  affection,  perhaps 
due  to  auto-intoxication,  beginning  in  the  first  ten  years  of  life  and 
progressing  slowly  "with  intervals  of  quiet,  death  occurring  in  ten 
or  twelve  years — either  from  some  intercurrent  disease,  especially 
bronchopneumonia,  or  from  inanition  due  to  involvement  of  the 
masseter  muscles."  (W.  Walker,  1908.)  The  thumbs  and  great  toes 
usually  have  a  congenital  deformity  (microdactylia)  consisting  in 
shortening  of  the  metacarpal  or  metatarsal  bones,  sometimes  with 
ankylosis  of  the  phalanges  (Fig.  282).  The  muscles  oftenest  affected 
are  in  the  trunk,  the  upper  extremity,  and  the  neck,  especially  the  tra- 
pezius, latissimus  dorsi,  sterno-mastoid,  and  shoulder  muscles  (Fig.  283) . 
The  disease  begins  with  soreness  and  stiffness  in  the  affected  muscles, 


CONTRACTURES  OF  MUSCLES 


307 


Fig.  281. — Skiagraph  of  myositis  ossificans  traumatica.    New-formed  bone  in 
brachialis  anticus  muscle.    Aged  twenty-one  years.    Episcopal  Hospital. 


attended  by  local  cyanosis  and  doughiness.  After  weeks  or  months 
another  exacerbation  occurs,  and  finally  bony  masses  become  palpable 
and  demonstrable  by  the  x-ray.    No  treatment  has  been  of  any  avail. 

Contractures  of  Muscles  resulting 
in  limitation  of  articular  motion  (false 
ankylosis),  follow  rheumatic,  gouty, 
or  other  inflammations,  but  are  of 
special  interest  to  surgeons  in  cases 
of  infantile  palsy  or  patients  with 
bone  and  joint  disease.  Weight  ex- 
tension, the  use  of  a  Stromeyer  splint 
(for  making  graduated  flexion  or  exten- 
sion by  means  of  a  double-threaded 
screw),  elastic  traction,  massage,  pas- 
sive motion, etc.,  sometimes  are  efficient 
in  overcoming  the  deformity,  but  not 
infrequently  mobilization  under  anes- 
thesia, or  myotomy  and  tenotomy  are 
required.     If  the  joint  capsule  is  the        FlG.  282.  —  Microdactylia  in  a 

Seat  of  contracture,  it  mav  have  to  be      case  of  myositis   ossificans   progres- 
,     ,  /n       tt         r>oj  i  nrx-  \      siva.    (Dr.  Warren    Walkers  case.) 

incised  also.     (See  Ings.  284  and  285.;     children's  Hospital. 


:;os 


I  \. I  DRIES  AX l>   DISEASES  OF  MUSCLES 


Ischemic  Contracture  (see  p.  583). 

Trichuriasis. — Ingestion  of  the  embryos  of  trichina  spiralis,  a 
parasite  infesting  uncooked  pork,  is  followed  by  their  migration  to 
and  development  in  the  muscular  tissues.     Within  a  week  or  ten 


Fig.  283. — Myositis  ossificans  progressiva  showing  deposits  in  muscles  of  back. 
(Dr.  Warren  Walker's  case.)    Children's  Hospital. 


Fig.  '-'84. — Contractures  of  ilio-psoas  muscles  following  neglected  case  of  Pott's 
disease  of  spine.     Children's  Hospital. 


Fig.  285. — Contractures  of  feet,  following  paralysis  of  extensor  muscles  from  fracture 
of  tenth  and  eleventh  thoracic  vertebrae,  five  years  previously.   Episcopal  Hospital. 

days  after  eating  the  contaminated  food,  the  patient  is  attacked 
with  muscular  soreness,  widely  distributed,  which  frequently  is 
regarded  as  rheumatic.  Diarrhea  often  is  present,  and  fever  is  usual. 
Examination  of  the  blood  shows  eosinophilia   (even  as  high  as  50 


SUBCUTANEOUS  RUPTURE  OF  TENDONS  300 

per  cent.)-  Microscopical  examination  of  excised  muscular  tissue 
confirms  the  diagnosis.  Beyond  purgation,  treatment  is  of  little 
value;  and  the  duration  of  the  disease  appears  to  be  self  limited 
to  a  few  weeks. 

Tumors  of  Muscles. — Rhabdomyoma  and  leiomyoma  have  been 
discussed  at  p.  115.  Desmoids  are  tumors  growing  from  muscle  or 
fascia,  usually  of  the  abdominal  wall,  analogous  to  keloids  in  the 
skin.  They  usually  are  single,  oftenest  arise  after  pregnancy  or  in 
an  operative  cicatrix,  and  sometimes  recur  after  extirpation,  assuming 
sarcomatous  characteristics. 

INJURIES   AND  DISEASES  OF  TENDONS. 

Wounds  of  Tendons. — Wounds  of  tendons  are  of  frequent  occur- 
rence, and  often  are  followed  by  marked  disability,  owing  to  adhesion 
of  the  tendons  to  their  sheaths,  to  each  other,  to  the  skin,  to  bone, 
etc.,  even  if  careful  primary  suture  has  been  done.  Tendons  retract 
when  divided,  and  the  surgeon  must  not  hesitate  to  enlarge  the 
original  wound  to  find  the  divided  ends.  Usually  it  is  better  to 
administer  a  general  anesthetic,  especially  in  wounds  of  the  flexor 
tendons  above  the  wrist.  Mattress  sutures  are  preferable,  and  if  the 
ends  cannot  be  made  to  meet,  tendon  lengthening  ma}'  be  employed 
(Fig.  308).  Free  transplants  of  tendons  (p.  240)  are  not  often  suc- 
cessful in  recent  injuries. 


Fig.  286. — Rupture  of  long  head  of  biceps  brachii,  forty-eight  hours  after  accident, 
from  violent  contraction  while  leading  unruly  horse  by  halter.  Dr.  G.  G.  Davis's 
case.     Orthopaedic  Hospital. 

Subcutaneous  Rupture  of  Tendons  is  more  frequent  than  that  of 
their  muscular  bellies.  Usually  it  occurs  only  in  already  slightly 
diseased  tissues,  especially  in  cases  of  periarthritis  (p.  507),  dystrophic 
arthritis,  etc.  Following  a  sudden  strain,  the  patient  is  conscious 
of  something  giving  way,  perhaps  with  an  audible  snap;  severe 
stinging  pain  occurs,  and  the  part  is  disabled.  Ecchymosis  appears 
subsequently,  and  when  the  affected  muscle  is  voluntarily  contracted, 
a  characteristic  deformity  is  seen,  owing  to  the  loss  of  attachment 
of  the  tendon.  The  biceps  brachii,  especially  its  long  scapular  head, 
(Fig.  280),  and  the  quadriceps  femoris  are  often  affected;  rupture  of 
one  of  the  tendons  of  the  extensor  longus  digitorum  near  its  insertion 


310 


tNJURlES  AND  DISEASES  OF  TENDONS 


in  the  finger  is  not  unusual  (Fig.  287).  So-called  rupture  of  the  plan- 
taris  probably  is  not  as  frequent  as  supposed  (p.274).  [n  the  pha- 
langes,  firm  bandaging  on  a  splint  for 
several  weeks  may  prevent  permanent 
deformity  or  disability;  in  other  eases 
the  affected  tendon  should  be  sutured. 
Dislocation  of  Tendons  may  be  patho- 
logical or  traumatic.  The  former  is 
more  frequent,  and  is  secondary  to 
changes  in  the  contour  of  the  neigh- 
boring joints,  or  to  peri-arthritic  lesions 
causing     obliteration     of     the     natural 


Fig.  287. — Rupture  of  tendon  of  extensor 
longus  digitorum  to  fifth  finger;  from  fall  on 
hand  two  months  ago.    Episcopal  Hospital. 


Fig.  288. — Luxation  of  pero- 
neal tendons  in  front  of  external 
malleolus  of  left  foot,  following 
paralytic  calcaneus.     Orthopaedic 

Hospital. 


groove  in  which  the  tendon  lies.  In  cases  of  infantile  paralysis 
with  marked  calcaneus  deformity  the  peroneal  tendons  may  be 
luxated  anterior  to  the  external  malleolus  (Fig.  288);  in  cases 
of  knock-knee  or  simple  relaxation  of  tissues  around  the  knee- 
joint,  outward  luxation  of  the  patella  may  occur  (p.  448);  in  peri- 
arthritis of  the  shoulder,  inward  dislocation  of  the  long  head  of  the  biceps 
sometimes  is  seen,  allowing  a  subluxation  forward  of  the  head  of  the 
humerus.  These  deformities  may  be  remedied  by  operation  if  dis- 
ability is  marked.  Correction  of  any  predisposing  deformity  is  the 
first  step.  In  the  case  of  the  patella  a  suitable  knee-cap  may  give 
relief,  or  the  inner  portion  of  the  capsule  may  be  pleated  on  itself, 
or  the  point  of  insertion  of  the  tendo  patellae  may  be  shifted  inward. 
The  capsule  of  the  shoulder  may  be  pleated,  and  the  biceps  tendon 
shortened. 

Strains  of  Tendons  are  of  frequent  occurrence.  Minute  extrava- 
sations occur  among  the  ruptured  fibers,  and  the  tendon  is  swollen, 
painful,  and  tender.  Schanz  (1905)  has  called  particular  attention  to 
traumatic  inflammation  of  the  tendo  Achillis,  which  often  is  mistaken 
for  achillodynia  (p.  298).  Some  cases  of  "trigger  finger"  (p.  586) 
may  have  a  similar  origin.  The  treatment  is  rest  during  the  acute 
stage,  followed  by  massage. 

Tenosynovitis  or  Thecitis  is  the  name  given  to  a  form  of  inflam- 
mation of  tendon  sheaths  usually  caused  by  repeated  trauma  (strains), 


PARONYCHIA  OR  PANARIS 


311 


in  those  predisposed  to  rheumatic  conditions.  It  occurs  oftenest 
in  the  extensor  tendons  at  the  wrist,  but  is  also  seen  at  the  ankle, 
and  elsewhere.  There  is  a  fine  crackling  and  creaking,  appreciable 
on  palpation  and  sometimes  audible,  whenever  the  affected  tendons 
are  moved;  this  is  caused  by  effusion  of  plastic  lymph  between  the 
tendon  and  its  sheath.  The  disease  never  progresses  to  the  stage 
of  suppuration.     Poncet  considered  it  of  tuberculous  origin. 

Treatment. — Treatment  consists  in  splinting  the  part  and  applying 
ointments  -  of  ichthyol  or  of  belladonna  and  mercury,  iodin,  etc. 
Local  rest  should  be  insisted  on  until  physical  signs  have  been  absent 
for  a  week  at  least;  otherwise  recurrence  is  usual.  With  prompt 
treatment  work  generally  may  be  resumed  in  a  few  weeks. 

Tuberculosis  of  Tendon  Sheaths  usually  is  secondary  to  tuber- 
culous synovitis  or  arthritis  (p.  519).  See  also  Tuberculous  Ganglion, 
p.  315. 

Paronychia  or  Panaris. — This  is  a  rather  vague  term,  denoting 
a  septic  inflammation  about  the  finger  tips  (very  rarely  of  the  toes). 
(1)  Properly  speaking,  it  implies  an  inflammation  about  the  matrix  of 
the  nail,  usually  starting  in  children  from  a 
hang-nail  (agnail),  and  appearing  as  a  red, 
tender,  swollen,  semicircle  around  the  base 
of  the  nail.  Hot  boric  acid  fomentations 
may  arrest  the  inflammation  if  applied 
early.  As  soon  as  suppuration  is  suspected, 
a  longitudinal  incision  should  be  made  on 
one  or  both  sides  of  the  nail  (Fig.  289), 
involving  neither  the  nail  itself  nor  the 
cuticle  at  its  base.  The  flap  so  outlined  is 
raised  from  the  nail,  discovering  the  sup- 
puration around  the  matrix,  under  the  nail. 
The  latter  must  now  be  raised  and  partly 
excised.  The  distal  part  of  the  nail  may  be 
left  intact,  and  will  be  pushed  gradually  out 
by  the  new-formed  nail  growing  as  the  suppu-       FlG-    289-  —  incisions  for 

...,1,1  ,  •         .  •      ,  •  /r4N      paronychia  (index  fin<ier)  and 

ration  is  checked  by  antiseptic  dressings.    (2)    digital  abscess  (thumb). 
Digital  abscess:   an  abscess  in  the  pulp  of  the 

finger-tip  not  involving  tendon  or  bone,  may  arise  from  a  pin-prick  or 
from  no  recognizable  injury.  The  finger-tip  becomes  extremely  painful, 
tender,  throbbing  and  swollen;  the  patient  spends  a  sleepless  night; 
home  remedies  bring  little  relief,  and  unless  the  pus  is  promptly 
relieved  by  incision,  the  tendon  sheath  (whitlow)  and  frequently  the 
phalanx  (felon)  become  involved.  The  abscess  should  be  opened  by 
an  incision  in  the  long  axis  of  the  finger,  on  one  or  both  sides,  never 
in  the  midline.  Dorrance  (1913)  cuts  all  around  the  finger-tip,  on 
the  dorsal  side  of  the  nerves,  and  turns  the  pulp  down  as  a  flap;  a 
strip  of  rubber  tissue  is  passed  across  for  drainage  (Fig.  289).  (3)  If 
the  tendon  sheath  is  invaded  the  entire  finger  becomes  painful,  is 
held  rigid  in  slight  flexion,  and  the  course  of  the  tendon  is  tender  to 


312 


INJURIES  AND   DISEASES  OF   TEXDOAS 


palpation.  There  is  much  edema  of  all  surrounding  parts.  Infection 
of  the  fifth  finger  or  thumb  may  spread  rapidly  to  the  palm  invading 
respectively  the  ulnar  or  the  radial  bursa  and  extending  above  the 
annular  ligament  at  the  wrist.  Only  when  incision  is  done  at  the 
earliest  stage  can  sloughing  of  the  tendon  be  prevented.  This  will 
result  in  very  slow  healing  and  a  stiff  or  deformed  finger  (Fig.  291). 
Therefore  the  tendon  sheaths  are  to  be  opened  as  soon  as  their  infection 
is  recognized,  by  free  incision  along  the  sides  of  the  proximal  and 


Fi<;.  290. — Incisions  for  infection  of  the  tendon  sheaths;  and  to  open  the  space 
anterior  to  the  pronator  quadratus. 

middle  phalanges  (Fig.  290);  it  is  best  not  to  make  the  incision 
through  the  sheath  continuous  from  one  phalanx  to  the  next,  for  fear 
prolapse  of  the  tendon  might  occur  (Kanavel,  1912);  but  in  severe 
cases  this  is  necessary  (nearly  always  when  the  fifth  finger  is 
involved),  as  well  as  incisions  on  both  sides  of  the  finger.  The  ulnar 
and  radial  bursas  are  to  be  opened  by  incisions  in  the  palm  over  their 
known  course,  following  the  pus  from  the  point  of  primary  drainage. 
If  extension  above  the  annular  ligament  has  occurred,  pus  almost 


Fig.  291. — Deformity  following  destruction  of  flexor  tendons  from  whitlow. 
Episcopal  Hospital. 

always  has  ruptured  the  bursa  and  lies  upon  the  pronator  quadratus. 
This  space  is  drained  by  an  incision  8  to  10  cm.  long  on  the  ulnar  aspect 
of  the  forearm,  well  posterior  to  ulnar  vessels  and  nerve  (Fig.  290);  a 
counter-incision  for  through-and-through  drainage  is  then  made  along 
the  radius.  For  all  these  incisions  a  general  anesthetic  is  to  be  preferred. 
After  operation  drainage  by  strips  of  rubber  tissue  should  be  provided 
for  twenty-four  to  forty-eight  hours,  and  the  hand  then  placed* in 
a  continuous  bath  of  saline  or  boric  acid   solution.     Vertical  sus- 


PAROXYCHIA   OR   PANARIS 


313 


pension  for  the  first  day  or  so  causes  rapid  subsidence  of  edema.  (4) 
Involvement  of  certain  fascial  spaces  (Fig.  294)  in  the  hand  and  fore- 
arm has  been  particularly  studied  by  Kanavel  (1912).  These  may  be 
invaded  primarily  from  direct  injury,  but  more  often  as  a  sequel  to 


Fig.  292. — Palmar  abscess ;  duration, 
one  week;  showing  ineffectual  incisions 
made  three  days  ago.  Episcopal  Hos- 
pital. 


Fig.  293. — Whitlow;  spontaneous  rup- 
ture; duration  eleven  days;  untreated. 
Children's  Hospital. 


infection  of  the  tendon  sheaths  or  of  fissures  of  the  palmar  skin:  (a) 
Upon  the  palmar  surface  of  the  adductor  transversus  pollicis  lies  the 
thenar  space,  usually  receiving  infection  from  the  index  finger  or  thumb; 
it  is  drained  by  an  incision  on  the  dorsal  surface  of  the  web  of  the 
thumb  close  to  the  index  metacarpal;  and  in  thrusting  the  forceps  into 


Fig.  294.— Formalin  section  of  hand  showing  palmar  spaces,  (a)  thenar  space;  (b) 
middle  palmar  space;  (c)  ulnar  bursa;  (d)  dorsal  subaponeurotic  space.  University  of 
Pennsylvania. 

the  palm  to  open  the  space,  care  should  be  taken  not  to  push  it  so  far 
as  to  carry  infection  into  the  middle  palmar  space,  (b)  The  viiddle 
palmar  space  has  as  its  usual  sources  of  infection  lesions  of  the  third, 
fourth  or  fifth  finger,  or  ulnar  bursa.     In  it  lie  the  lumbrical  muscles 


31  l 


INJURIES  AM>  DISEASES  OF  TEXDO.XS 


of  these  fingers,  and  infection  may  travel  along  them  to  the  web  of  the 
fingers,  the  pus  pointing  here  on  the  dorsal  aspeet.  This  is  almost 
the  only  lesion  which  causes  bulging  or  even  merely  obliteration  of 
the  palmar  concavity.  It  is  best  drained  by  an  incision  in  the  palm 
from  the  web  between  the  third  and  fourth 
ringers  up  about  4  cm.;  the  space  (lying- 
deeper  than  the  tendons)  is  then  opened 
by  Hilton's  method  (p.  50).  (c)  Envel- 
oping the  ulnar  side  of  the  -flexor  tendons 


Fig.  29G. — Bilocular  ganglion 
Fig.  295. — Ganglion  on  extensor  surface  of  wrist  (see     excised  from   wrist    (see    Fig. 
Fig.  296).     Episcopal  Hospital.  295).     Episcopal  Hospital. 

is  the  ulnar  bursa,  commonly  involved  by  extension  from  the  fifth 
finger,  (d)  On  the  dorsum  of  the  hand  is  the  subaponeurotic  space, 
lying  between  the  extensor  tendons  and  the  bones,  and  continuous 
distally  with  corresponding  spaces  in  the  fingers,  and  connecting 
also  wTith  the  palmar  spaces  along  the  lumbrical  muscles.  (5)  Necrosis 
of  the  distal  phalanx  (usually  not  extending  to  its  base)  often  com- 
plicates a  neglected  paronychia  or  digital  abscess,  and  requires  ampu- 
tation. Necrosis  of  other  phalanges  or  metacarpals  is  rare  unless  the 
infection  originated  in  a  compound  fracture. 


Fig.  297. — Tuberculous  ganglion  of  right  wrist  and  palm  (hour-glass  swelling). 
Aged  forty-two  years;  duration,  five  years.    Orthopaedic  Hospital. 

Ganglion. — A  ganglion  is  a  cyst  developed  in  connection  with  a 
tendon  sheath,  or  from  the  subsynovial  tissues  of  a  joint  capsule.  Its 
pathogenesis  is  not  well  understood,  but  probably  is  a  degenerative 
change  (Clarke,  1908).  Frequently  slight  trauma  has  occurred,  but 
often  no  such  history   can  be  obtained.     Ganglia  occur  oftenest  in 


GANGLION 


315 


women,  being  especially  frequent  on  the  extensor  surface  of  the  wrist 
(Fig.  295) ;  they  are  seen  less  often  at  the  ankle  or  in  the  palm  of 
the  hand  (Fig.  297)  and  certain  bursal  enlargements  seem  clini- 
cally identical  with  ganglia  (Figs.  270 
and  298).  Occasionally  a  ganglion  con- 
tains rice-like  bodies,  similar  to  "joint- 
mice"  (p.  502,  520);  and  sometimes  a 
ganglion  is  frankly  tuberculous;  this  is 
especially  apt  to  be  the  case  in  "com- 
pound ganglia,"  where  the  cystic  mass 
is  more  or  less  lobulated,  possibly  as 
the  result  of  the  coalescence  of  several 
distinct  ganglia.  Syphilis,  usually  in  the 
secondary  stage  (Verneuil,  1868),  rarely 
congenital,  may  also  cause  bursal  or  ten- 
osynovial disease  (Coues,  1915). 

Treatment. — A  small  ganglion  may  be 
dispersed  by  a  smart  blow  with  a  heavy 
book,  the  part  being  splinted  subse- 
quently for  a  week  or  so;  recurrences 
may  be  expected  in  over  half  the  cases 
so  treated.  Safer  and  better  treatment  is 
formal  excision  of  the  ganglion  or  aspira- 
tion and  injection  of  2  per  cent,  formalin 
in  glycerin,  dilute  iodin  or  alcohol. 
Tuberculous  ganglia  never  should  be 
treated  by  attempts  at  rupture.  Syphi-  fig.  298.— Ganglia  in  popliteal 
litic  ganglia  usually  disappear  under  space;  aged  eighteen  years ;dura- 
■  •?  ,•         i     ,  i    ,         ,  tion,  over  one   year.     Episcopal 

constitutional   treatment  and  local  rest.      Hospital. 


INJURIES  AND  DISEASES  OF  NERVES. 

Contusion. — Contusion  of  a  nerve  produces  tingling  and  perhaps 
numbness  or  paralysis  in  its  distribution.    A  frequent  lesion  is  paralysis 


Fig.  299. — Paralysis  of  musculo-spiral  nerve  from  overlying. 

of  the  musculospiral  nerve  (less  often  of  the  circumflex)  from  pressure 
during  sleep  {overlying) — most  seen  after  a  debauch,  the  patient  having 


316 


INJURIES  AND  DISEASES  OF  NERVES 


lain  stuporous  for  many  hours  (Fig.  299).     In  other  cases  the  lesion 
results  from  a  sudden  blow  or  fall,  perhaps    from    sudden   abduction 

of  the  humerus  (Fig.  300). 
Crutch-palsy,  affecting  the  axil- 
lary nerves,  especially  the  mus- 
culospiral,  is  caused  by  the 
patient  bearing  most  of  his  weight 
on  the  axilla  instead  of  on  his 
hands,  usually  because  the  hand- 
bars  of  the  crutches  are  placed  too 
low.  Post-anesthetic  palsy  is  due 
to  direct  pressure,  the  arm  hav- 
ing been  allowed  to  hang  over  the 
edge  of  the  table  (museulospiral, 
ulnar);  or  from  pressure  on  the 
peroneal  nerve  below  the  head  of 
the  fibula.  This  latter  form  of 
paralysis  may  result  from  im- 
proper application  of  a  gypsum 
case.  As  a  rule,  the  only  treatment 
required  is  rest  upon  a  splint,  sup- 
porting the  paralyzed  muscles  ;with 
massage,  electricity,  etc.  Subcu- 
taneous rupture  is  extremely  rare, 
but  in  compound  fractures  or 
similar  accidents  a  nerve  ma}-  be 
crushed,  complete  destruction  of  the  nerve  fibers  occurring,  and  only  the 
sheath  remaining  to  connect  the  bruised  ends  of  the  nerve.  The  signs 
of  loss  of  function  due  to  such  nerve  injuries  usually  are  subordinate 
to  those  due  to  the  lesions  of  the  muscles,  tendons,  and  bones;  but  in 
all  such  accidents  the  surgeon  should  make  tests  for  sensation  and 
motion  in  the  part  supplied  by  any  nerves  which  possibly  might  have 
been  injured.  Resection  of  the  damaged  portion,  with  end-to-end 
union  of  the  nerve  stumps  should  be  done,  as  described  under  Wounds 
of  Nerves  (p.  318). 

Dislocation. — Dislocation  of  a  nerve  is  rare.  Occasionally  the 
ulnar  nerve  slips  in  front  of  the  internal  condyle,  and  causes  moderate 
disability.  Operation  generally  is  necessary  to  replace  such  nerves 
and  consists  in  restoring  normal  relations  and  suturing  a  layer  of 
fascia  over  the  nerve  to  hold  it  in  place. 

Stretching  or  Laceration. — Stretching  or  laceration  of  nerves  may 
occur  as  a  subcutaneous  injury.  In  dislocations  or  sprains  of  the 
shoulder  the  circumflex,  and  more  rarely  the  museulospiral  nerve, 
may  thus  be  damaged;  or  rarely  the  cords  of  the  brachial  plexus 
may  be  injured.  (See  also  Neuritis,  p.  320,  Periarthritis,  p.  507,  and 
Birth  Injuries  of  the  Shoulder,  p.  556.)  According  to  Vandenbossche 
(1910)  it  is  probable  that  in  most  of  these  latter  cases  the  lesion  is  in 
the  nerve  roots  rather  than  in  the  brachial  plexus.     Duval  and  Quillain 


Fig.  300. — Paralysis  of  left  circumflex 
nerve  with  atrophy  of  deltoid  muscle, 
from  sprain  of  shoulder  five  months  ago. 
Patient,  aged  sixty  years,  fell  twenty-seven 
feet.     Episcopal  Hospital. 


s  a 

!-     6. 


A/" 


STRETCHING  OR  LACERATION 


317 


(1898)  maintained  that  there  were  no  such  clinical  entities  as  paralyses 
due  to  lesions  of  the  plexus,  only  two  types  existing,  radicular  and 
terminal,  affecting  either  the  spinal  motor  roots  or  the  nerve  trunks 
below  the  plexus.  Rupture  of  the  nerve  sheaths  occurs  first,  and 
there  is  more  or  less  laceration  of  the  nerve  fibers  themselves;  intra- 
and  perineural  hemorrhage  occurs,  with  marked  cicatricial  changes 
in  the  surrounding  fascia. 

If  no  improvement  occurs  after  proper  splinting  (to  take  all  strain 
off  paralyzed  muscles)  and  persistence  in  use  of  massage  and  electricity 
for  several  months;  or  at  once,  if  complete  rupture  is  believed  to 
exist,  the  nerves  should  be  exposed  by  incision,  and  treated  as  may  be 
indicated:  Neurolysis  (dissection  from  adhesions),  neurectomy  (when 
a  scar  exists  which  will  not  transmit  the  Faradic  current)  and  resuture, 
or  simple  suture  of  the  ruptured  ends  may  be  required.  After-treat- 
ment is  the  same  as  after-operations  for  wounds  of  nerves  (p.  319). 


Fig.  3  J  I. — Deformity  following  Volkmann's  ischemic  contracture  and  paralysis 
of  ulnar  nerve  after  fracture  of  elbow.     Orthopaedic  Hospital. 

When  the  motor  roots  in  the  neck  (above  the  brachial  plexus)  are 
ruptured,  Alexinsky  (1899)  proposed  transplanting  the  peripheral 
ends  of  the  damaged  nerve  roots  to  the  opposite  side  of  the  neck,  and 
uniting  them  to  the  central  ends  on  the  other  side;  a  similar  operation 
has  been  done  by  Babcock  (1907),  in  a  case  of  anterior  poliomyelitis. 
Muscle  and  tendon  transplantation  often  will  give  better  results  than 
any  operations  on  the  nerves. 

Wounds  of  Nerves — These  may  bean  incident  in  extensive  lacerated 
wounds  involving  muscles,  tendons,  and  bloodvessels;  or  isolated 
injuries  due  to  stab  wounds  (Fig.  302).  The  symptoms  are  complete 
loss  of  function  in  the  distribution  of  the  injured  nerve;  usually  this 
implies  loss  of  both  motion  and  sensation.  If  only  a  peripheral  sen- 
sory nerve  is  divided,  sensation  may  return  in  time,  even  if  the  ends 
of  the  nerve  are  not  sutured;  this  is  due  in  part  to  regeneration,  and 
in  part  to  collateral  circulation,  as  it  were,  in  surrounding  nerve 
filaments.  But  unless  the  ends  of  a  motor  nerve  are  brought  into 
accurate  apposition  by  suture,  paralysis  of  motion  will  be  permanent. 
After  suture,  the  prognosis  is  uncertain,  though  if  suture  is  done  soon 


318 


INJURIES  AND  DISEASES  OF  NERVES 


after  the  accident  {primary  suture)  more  or  less  complete  recovery 
is  the  rule  (Figs.  303  and  304) ;  after  secondary  suture  the  results  are 
very  uncertain  (Figs.  305  and  300). 

Howell  (1S92)  collected  84  cases  of  prim- 

IB^^^^k]  ary  nerve  suture  in  civil  life,  with  12  per 
cent,  successful  results,  and  40  per  cent, 
improved;  and  80  cases  of  secondary  suture, 
with  38  per  cent,  successful,  and  50  per 
cent,  improved.  Souttar  and  Twining 
(1918)  found  among  61  cases  of  secondary 
suture  for  war  wounds,  14  per  cent,  were 
traced  to  recovery,  68  per  cent,  were  re- 
covering, 14  per  cent,  were  doubtful,  and 
only  4  per  cent,  were  failures. 

Treatment.  —  A  recently  wounded  nerve 
should  be  exposed,  and  all  damaged  tissue 
excised  with  a  sharp  knife.  Scissors  bruise 
nerves,  and  never  should  be  used.  The 
ends  are  then  united  (neurorrhaphy) 
with  very  fine  silk  or  chromic  catgut  threaded  in  fine  round  needles. 
One  suture  at  least  should  be  passed  directly  through  the   nerve,  and 


Fig.  302. — Paralysis  of  pero- 
neal nerve  following  injury  of 
cauda  equina  in  spinal  anes- 
1  hesia ;  seventeen  months'  dura- 
tion.    Orthopaedic  Hospital. 


Fig.   303. — Recovery  after  primary  suture  of  musculospiral  nerve,  for  stab 
wound.    Episcopal  Hospital. 


Fig.   304. — Recovery  of  function  after  primary  suture  of  musculospiral  nerve 
for  stab  wound.    Episcopal  Hospital. 


tied  just  tight  enough  to  approximate  without  constricting  the  ends; 
other  sutures  of  chromic  gut  should  then  be  applied  merely  through  the 


WOUNDS  OF  NERVES 


319 


nerve  sheath,  to  relieve  strain,  and  prevent  adhesions  of  the  nerve 
fibers  to  surrounding  structures  (Fig.  307).  If  for  any  reason,  the  ends 
of  the  nerves  cannot  be  made  to  meet  (even  by  free  dissection  of  the 
nerve  trunk  above  and  below  the  lesion,  and  by  flexing  neighboring 
joints),  both  ends  may  be  very  cautiously  stretched,  or  neuroplasty  may 


Fig.  305. — Stab  wound  of  median  nerve  just  after  operation  of  secondary  suture 
(three  months  after  injury) ;  showing  inability  to  flex  wrist,  index  finger,  and  thumb 
(see  Fig.  306).     (Dr.  Harte's  case.)     Orthopedic  Hospital. 

be  done  (Fig.  308).  It  is  in  cases  of  secondary  suture  that  the  largest 
gaps  may  have  to  be  spanned,  as  it  is  necessary  to  excise  all  scar 
tissue  until  projecting  ends  of  nerve  fibers  can  be  seen  in  cross-section.1 
A  layer  of  muscle  or  a  free  transplant  of  fascia  lata,  should  then  be 
sutured  over  the  nerve,  to  protect  it;  the  wound  should  be  closed;  and 
the  limb  kept  at  rest  for  two  or  three  weeks,  when  light  massage, 
electrotherapy,  etc.,  may  be  com- 
menced. Sensation  returns  long 
before  motion,  sometimes  within 
a  few  days ;  but  hope  of  motion 
should  not  be  abandoned  for  about 
a  year  after  suture,  unless,  of 
course,  it  can  be  shown  that  the 
sutures  have  given  way.  Under 
such  circumstances  the  operation 
may  be  done  over  again.  In  all 
cases  development  of  deformity 
must  be  prevented  by  splints, 
braces,  passive  motion,  etc.  Re- 
generation of  sutured  nerves  de- 
pends on  the  formation  of  new 
axones,  which  some  hold  develop 
from  proliferation  of  neurilemma 

cells  in  the  peripheral  segment,  while  others  maintain  that  in  all 
cases  the  axones  grow  out  from  the  central  segment,  and  have  to 
penetrate  the  distal  segment  to  its  various  terminations  before  function 

1  I  have  had  a  brilliant  result  of  secondary  neurorrhaphy  of  both  median  and 
ulnar  nerves  by  making  traction  on  the  bulbous  ends  until  they  overlapped  (thus 
spanning  a  gap  of  more  than  5  cm.),  denuding  the  nerves  laterally,  and  making  a 
lateral  anastomosis  in  healthy  nerve  tissue.  In  two  cases  of  neuroplasty  (one 
median  and  one  ulnar),  nearly  complete  function  has  been  restored. 


Fig.  306. — Recovery  of  function  eight 
months  after  secondary  suture  of  median 
nerve  (see  Fig.  305)  Note  power  of  flexing 
wrist,  index  finger,  and  thumb.  (Dr. 
Harte's  case.)     Orthopaedic  Hospital. 


)20 


INJURIES   AND  DISEASES  OF  NEW  ES 


is  restored.  At  present  very  little  credence  is  given  to  the  former 
view,  but  all  authorities  agree  that  the  proper  paths  persist  in  the 
distal  segment  waiting  to  be  penetrated  by  axones  from  the  central 
segment;  and  it  is  this  teaching  which  justifies  us  in  urging  late 
secondary  suture.     So  long  as  the  muscles  have  not  become  hopelessly 


Fig.  307. — Netve  suture:  one  suture  passes  completely  through  the  nerve; 
the  others  pass  through  the  sheath  only. 


degenerated,  nerve  suture  may  be  successful  (after  fourteen  years, 
Jacobson).  Nerves  which  have  no  neurilemma  do  not  regenerate; 
the  nerves  of  special  sense  have  no  neurilemma;  nor  have  the  spinal 
nerves,  except  peripheral  to  the  spinal  ganglia. 

Neuritis. — Neuritis,  as  the  term  usu- 
ally is  understood,  implies  not  a  reac- 
tion to  septic  infection,  but  a  form 
of  subacute  or  chronic  inflammation 
due  to  contusion,  to  pressure  (from 
cicatrices,  callus,  exostoses,  tumors, 
etc.),  to  recurrent  trauma  (occupation 
neuritis),  to  toxic  infections  (influenza, 
typhoid  fever,  etc.), intoxicants  (alcohol, 
lead,  etc.),  and  other  less  well  defined 
causes.  The  pathological  change  is 
proliferation  of  the  nerve  sheath  (epi- 
neurium,  perineurium,  and  endoneu- 
rium),  which  compresses  the  nerve  fibers 
(axones),  leading  to  pain,  impairment 
of  function,  and  various  trophic  dis- 
turbances in  the  distribution  of  the 
affected  nerve.  The  nerve  trunk  is 
hyperemic,  perhaps  edematous,  swollen, 
and  bulbous.  Perineural  adhesions  are 
frequently  present. 

Symptoms. — The  onset  may  be  sudden, 
after  exposure  to  cold,  after  violent  exer- 
tions, or  any  factor  wThich  reduces  the 
patient's  vitality.  Pain  is  present  in  the  portion  of  the  nerve  diseased, 
and  also  shoots  along  the  course  of  this  nerve,  usually  in  a  peripheral 
but  sometimes  in  a  central  direction.  There  is  tenderness  along 
the  course  of  the  nerve,  and  cutaneous  hyperesthesia  may  be  very 
marked;  numbness  and  a  sense  of  swelling  (vaso-motor  or  trophic 
disturbances)  may  be  present  in  the  area  of  distribution.     The  skin 


Fig.  308.  —  Neuroplasty.  The 
proximal  segment  is  split  and  a  flap 
is  turned  down  and  sutured  to  the 
distal  segment.  (Tendon  length- 
ening may  be  done  in  similar  man- 
ner.    See  p.  309.) 


NEURITIS 


321 


becomes  glossy,  appears  tense  and  hyperemia;  sweating  usually  is 
diminished;  incurvation  or  shedding  of  the  nails  may  occur  (Fig.  309) ; 
the  muscles  become  atrophic  and  contractures  and  reactions  of 
degeneration  may  develop. 

The  nerve  trunks  most  often  affected  are  those  of  the  brachial 
plexus,  the  masculospiral,  ulnar,  and  median,  and  the  sciatic.  It 
must  be  remembered  that  the  neuritis  may  be  only  a  symptom  of 
another  affection  (periarthritis  of  the  shoulder,  p.  507;  ischemic 
contracture,  p.  583;  sacro-iliac  or  hip-joint  disease,  p.  57S;  etc.). 


Fig.  309. — Photograph  showing 
trophic  changes  in  finger  nails  as  a 
result  of  neuritis  of  median  nerve. 
January  31,  1907.  Episcopal  Hos- 
pital. 


Fig.  310. — Photograph  made  eight  weeks 
after  neurolysis  (from  callus  at  elbow),  to  show 
improvement  in  finger  nails.  (See  Fig.  309). 
Episcopal  Hospital. 


Treatment. — Treatment  comprises,  first  and  foremost,  removal 
of  the  cause,  whenever  this  can  be  discovered  (callus,  tumor,  cicatrix, 
etc.).  In  all  cases  rest  is  of  utmost  importance,  and  should  always 
be  the  first  step  when  no  obvious  cause  exists.  Counter-irritation 
sometimes  is  of  value.  The  patient's  general  health  should  be  im- 
proved. Antiseptics  may  be  administered  internally,  especially  the 
salicylates.  Electrotherapeusis,  massage,  and  baking,  are  suitable 
only  for  the  chronic  stages,  after  rest  has  allayed  the  acuter  symp- 
toms. In  many  cases  operation  is  of  benefit  (Fig.  310),  especially 
neurolysis  (dissection  of  the  nerve  trunk  and  even  dissociation  of  its 
fibers);  neurectasy  (nerve-stretching)  is  a  less  certain  operation,  though 
21 


322  INJURIES  AND  DISEASES  OF  NERVES 

aiming  to  accomplish  the  same  results;  neurotomy  and  neurectomy 
(except  when  purely  sensory  branches  are  involved)  seldom  arc  justi- 
fiable until  other  operations  have  failed. 

Neuralgia. — Neuralgia,  signifying  pain  in  a  nerve  for  which  no 
pathological  lesion  can  be  held  accountable,  remains  an  inscrutable 
problem;  and  to  state,  as  is  often  done,  that  such  changes  as  may 
be  found  on  microscopical  examination  of  the  affected  nerve  are 
the  result,  not  the  cause  of  the  disease,  in  no  way  renders  the  subject 
easier  to  understand.  In  a  word,  neuralgia  is  held  to  be  a  functional 
neurosis.  Many  cases  of  supposed  neuralgia,  however,  will  be  found 
on  careful  investigation  to  be  due  to  referred  pain  from  definite  lesions 
elsewhere.    Many  are  really  cases  of  neuritis. 

Symptoms. — Its  symptoms  differ  somewhat  from  those  of  neuritis; 
the  pain  is  equally  great,  but  may  come  and  go  without  apparent 
cause;  it  is  more  burning  and  aching  than  sharp  and  shooting  in 
character;  is  more  influenced  by  damp  weather  and  exposure  to 
cold;  and  is  unattended  with  actual  changes  in  the  overlying  tissues, 
which  are  common  in  neuritis.  The  tenderness  does  not  extend  over 
the  entire  course  of  the  affected  nerve,  but  is  most  intense  at  certain 
points  ("points  douloureux,")  especially  where  the  nerve  passes 
through  a  foramen  (intervertebral,  supraorbital,  mental,  etc.),  or 
through  the  deep  fascia;  and  pressure  on  the  nerve  with  the  palm  of 
the  hand  relieves  rather  than  aggravates  the  pain,  though  pressure 
by  the  finger  tip  or  pointed  instrument  may  bring  on  an  exacerbation 
of  pain. 

Treatment. — Treatment  is  much  the  same  as  for  neuritis,  which 
often  can  be  excluded  from  the  diagnosis  only  after  prolonged  rest 
has  failed  to  give  relief.  Injections  of  alcohol,  osmic  acid  (1  per 
cent.),  and  other  substances  into  or  around  the  nerve  have  been 
adopted  in  many  cases  with  varying  results  (p.  323).  Neurectasis, 
neurolysis,  and  even  neurotomy  and  neurectomy  may  be  done. 

The  forms  of  neuralgia  most  important  to  the  surgeon  are: 
Neuralgia  of  the  fifth  cranial  nerve;  Brachial  Neuralgia  (which  has 
been  sufficiently  discussed  under  the  heading  Neuritis);  and  Sciatic 
Neuralgia. 

Neuralgia  of  the  Fifth  Cranial  Nerve;  Tri-Facial  Neuralgia  or  Tic 
Douloureux. — The  pathology  of  this  affection  is  very  little  under- 
stood. Two  types  are  recognized:  the  minor  neuralgia,  and  the  major 
or  epileptiform  neuralgia.  In  the  former,  which  probably  is  a  true 
neuralgia,  there  is  more  or  less  continuous  pain,  but  it  is  not  exces- 
sively severe;  usually  some  local  or  constitutional  cause  can  be  found, 
and  on  remedying  this  the  neuralgia  may  stop  for  a  time  or  permanently. 
Among  such  causes  are  caries  of  the  teeth,  sinus  diseases,  malaria,  lead 
poisoning,  chronic  nephritis,  gout,  etc.  The  major  neuralgias,  on 
the  contrary,  appear  to  be  due  to  some  central  lesion  which  involves 
the  Gasserian  ganglion  either  primarily  or  by  extension  from  disease 
of  its  branches,  or  possibly  by  pressure  from  some  intracranial  growth. 
This  form  of  the  disease  is  characterized  by  progressively  severer 


NEURALGIA  OF  THE  FIFTH  CRANIAL  NERVE  323 

attacks  of  neuralgic  pain,  extending  over  months  or  years  and  affect- 
ing one  or  more  branches  of  the  fifth  cranial  nerve,  with  no  discover- 
able cause.  The  mandibular  and  maxillary  divisions  are  affected 
in  most  cases;  the  supraorbital  branch  rarely  is  affected  alone.  The 
attacks  may  be  brought  on  by  a  draft  of  air,  by  touching  the  side  of 
the  face  affected,  by  putting  food  into  the  mouth,  etc.  The  skin 
may  become  so  hyperesthetic  that  for  weeks  or  months  the  patient 
may  be  unable  to  wash  his  face;  he  may  be  unable  to  eat  because  of 
pain  aroused  in  the  lingual  and  inferior  dental  nerves;  and  a  state 
bordering  on  insanity  may  ensue  finally  unless  relief  is  obtained. 

Treatment. — It  should  be  ascertained  whether  any  local  or  con- 
stitutional cause  for  the  neuralgia  exists;  and  such  conditions  should 
receive  appropriate  treatment.  If  the  disease  belongs  to  the  major 
neuralgia  type  no  treatment  will  be  of  long  avail  unless  it  acts  directly 
on  the  nerves  or  ganglion  itself.  The  administration  of  salicylates, 
quinin,  opium,  or  other  drugs  may  be  useful  to  allay  the  pain  "tem- 
porarily and  thus  improve  the  general  health  before  surgical  treat- 
ment is  undertaken.  This  treatment  implies  destruction  of  the 
nerves  or  the  ganglion,  or  both.  The  operations  are  divided  into 
extracranial  or  peripheral  operations  and  intracranial  operations. 

Peripheral  Operations. — Injection  of  the  nerve  trunks  with  alcohol 
(Schlosser,  1907)  has  entirely  superseded  injections  with  osmic 
acid,  as  originally  advocated  by  Bennet  in  1897.  These  substances, 
especially  alcohol,  destroy  the  nerve  at  the  point  of  injection,  and 
though  regeneration  may  take  place  relief  is  secured  for  from  six  to 
eighteen  months,  rarely  for  longer  periods.  The  longest  period  of 
relief  secured  in  my  own  cases  was  twenty-seven  months.  Patrick, 
of  Chicago,  has  had  large  experience  with  alcohol  injections,  which  he 
makes  into  the  second  and  third  branches  where  they  emerge  from  the 
base  of  the  skull,  and  into  the  first  branch  at  the  supra-orbital  foramen. 
He  does  not  attempt  to  make  deep  injections  into  the  first  branch 
because  of  danger  to  other  structures  in  the  orbit. 

The  internal  maxillary  artery  with  its  branches,  including  the  middle 
meningeal,  is  directly  in  the  field  of  operation  and  renders  deep  injec- 
tions hazardous.  But  Patrick  has  had  no  bad  results  on  this  score 
in  150  cases.  The  needle  is  12  cm.  long,  1.75  mm.  thick,  is  not 
acutely  sharp,  and  is  provided  with  a  stylet.  To  inject  the  second 
branch,  the  needle  is  inserted  at  the  lower  border  of  the  zygoma 
just  in  front  of  the  coronoid  process  of  the  mandible  (0.5  cm.  behind 
a  perpendicular  let  fall  from  the  posterior  edge  of  the  orbital  pro- 
cess of  the  malar  bone);  it  points  upward  at  an  angle  of  about  30 
degrees  with  the  horizontal  plane  (the  patient  being  erect)  and  at 
a  right  angle  with  the  sagittal  plane;  while  the  third  division  is 
reached  from  a  point  at  the  lower  border  of  the  zygoma  2.5  cm.  in 
front  of  its  anterior  root,  the  needle  entering  in  the  horizontal  plane 
and  pointing  backward  at  an  angle  of  60  degrees  with  the  frontal 
plane.  A  tingling  sensation  in  the  distribution  of  the  nerve  indicates 
that  it  has  been  reached.  Usually  the  nerves  must  be  sought  for 
cautiously  by  inserting  the  point  of  the  needle  in  different  directions. 


324  INJURIES  AND  DISEASES  OF  NERVES 

The  foramen  rotundum  lies  about  5  em.,  and  the  foramen  ovale 
about  4  cm.  from  the  surface  About  2  c.c.  of  the  solution  are 
injected  into  each  nerve.  "  If  the  operator  feels  satisfied  that  the 
needle  is  in  the  nerve  (he  never  knows  it),"  writes  Patrick,  "less  is 
enough."  A  local  anesthetic  is  desirable.  The  injection  may  be 
repeated  in  a  few  days  if  the  first  attempt  proves  unsuccessful.  If 
bleeding  occurs  through  the  needle,  the  stylet  should  be  replaced  and 
the  needle  left  in  situ  until  clotting  occurs.  Hartel  worked  out  a 
method  of  injecting  the  Gasserian  ganglion,  which  has  been  employed 
in  this  country  by  Martin  (1915). 

Avulsion  of  the  Peripheral  Nerves  (Thiersch,  1889)  is  a  more 
formidable  procedure,  and  usually  secures  no  longer  freedom  from 
pain.  The  nerves  are  very  slowly  avulsed  by  wrapping  them  around 
a  forceps,  after  adequate  exposure.  The  second  and  third  branches 
of  the  fifth  nerve  may  also  be  approached  extracranially,  at  the 
base  of  the  skull,  by  various  routes,  involving  more  or  less  tedious 
and  delicate  operations.  These  methods  were  employed  chiefly  before 
the  general  adoption  of  alcoholic  injections;  they  are  now,  I  believe, 
very  properly  abandoned. 

Intracranial  Operations. — Extirpation  of  the  Gasserian  ganglion 
was  proposed  by  Mears,  of  Philadelphia,  in  1884,  and  first  per- 
formed by  E.  Rose  in  1890.  Rose  employed  the  pterygoid  ronte, 
trephining  the  base  of  the  skull.  Hartley,  of  New  York,  and  Krause, 
of  Altoona,  independently,  in  1892,  proposed  the  temporal  route, 
and  most  surgeons  now  employ  some  modification  of  the  Hartley- 
Krause  method.  Owing  to  the  difficulty  of  removing  the  entire 
ganglion  from  the  presence  of  adhesions  and  its  intimate  relation 
with  the  cavernous  sinus,  sixth  nerve,  etc.,  many  of  the  earlier 
operations  were  only  partial  excisions.  To  simplify  the  operation, 
Abbe  (1903),  merely  divided  the  second  and  third  branches  before 
they  left  the  skull,  and  interposed  a  strip  of  rubber  tissue  to  prevent 
their  reunion.  Spiller  (1901)  by  a  happy  inspiration  suggested  to 
Frazier  that  section  of  the  sensory  root  of  the  ganglion  would  amount 
to  a  physiological  extirpation  of  it,  since  this  root,  which  is  devoid  of 
neurilemma,  could  not  on  that  account  regenerate.  This  operation, 
as  pointed  out  by  Frazier,  is  easier,  is  attended  by  less  hemorrhage, 
does  not  expose  the  cavernous  sinus  or  sixth  nerve  to  injury,  leaves 
the  motor  root  (and  consequently  the  muscles  of  mastication)  intact, 
and,  finally,  involves  a  diminished  risk  of  keratitis,  which  was  so 
prone  to  follow  removal  of  the  entire  ganglion. 

Frazier-Spiller  Operation.- — A  flap  of  soft  parts  is  turned  down, 
care  being  exercised  not  to  injure  the  upper  branches  of  the  facial 
nerve.  A  sufficient  amount  of  bone  is  then  removed  from  the  temporal 
fossa,  with  trephine  and  rongeur,  and  the  dura  is  raised  from  the 
base  of  the  skull.-  Frazier  always  ligates  and  divides  the  middle 
meningeal  artery,  as  it  leaves  the  foramen  spinosum.  The  dura 
covering  the  mandibular  division  of  the  nerve  is  then  incised,  and  the 
ganglion  exposed.  If  the  motor  root  is  seen,  it  should  be  separated 
from  the  sensory;  this  latter  is  then  divided  or  avulsed.     The  brain 


NEURALGIA  OF  THE  SCIATIC  NERVE 


325 


is  then  allowed  to  fall  back  on  the  base  of  the  skull,  and  the  soft 
parts  are  closed  with  drainage.  The  mortality  following  the  operation 
in  the  hands  of  skilled  operators  is  less  than  4  per  cent.  The  chief 
dangers  are  shock,  hemorrhage,  and  infection. 

After-care. — For  weeks  or  months  after  operation  the  eye  of  the 
same  side  should  be  most  carefully  protected  by  a  shield  (an  automo- 
bile goggle  is  suggested  by  Frazier),  as  destruction  of  its  protecting 
nerve  supply  renders  the  cornea  exceedingly  prone  to  trauma  and 
infection,  and  many  patients  have  lost  their  sight  from  this  cause. 

Sciatic  Neuralgia  or  Sciatica. — This  is  not  regarded  as  so  frequent 
a  lesion  now  as  formerly,  since  it  has  been  shown  that  in  most  cases 
the  disease  really  is  a  neuritis,  or  is  merely  referred  pain  due  to  pelvic 


Fig.  311. — Sacro-iliac  sprain,  with  relaxation  (left  side).  For  eight  months  pain  in 
left  hip,  back,  and  down  sciatic.  Diagnosed  Pott's  disease,  elsewhere.  Orthopaedic 
Hospital. 

(Fig.  311)  or  hip  disorders.  If  no  cause  of  referred  pain  can  be  dis- 
covered, and  if  rest,  antirheumatic  drugs,  counter-irritation  (blistering, 
cauterization),  and  other  palliative  methods  are  ineffectual,  the  surgeon 
may  be  tempted  to  adopt  operative  measures,  on  the  theory  that  the 
affection  really  is  a  neuritis,  from  infection  or  trauma,  with  perineural 
adhesions. 

Neurectasis  may  be  secured  without  incision  by  forcibly  flexing  the 
thigh  on  the  abdomen  with  the  knee  fully  extended  (the  patient  being 
anesthetized);  or  by  exposing  the  sciatic  nerve  below  the  gluteus 
maximus,  either  on  the  inner  or  outer  side  of  the  biceps  muscle,  and 
stretching  it  over  the  finger  both  centrally  and  peripherally;  the 
patient  lying  on  his  face  it  is  safe  usually  to  employ  traction  sufficient 
just  to  raise  the  limb  from  the  table.     Neurolysis  is  a  safer  and  more 


326  INJURIES   AND  DISEASES  OF  NERVES 

certain  operation;  the  sheath  is  opened  and  the  nerve  fibers  separated 
from  it  and  from  each  other  for  a  distance  of  several  inches;  Pers 
(1908)  adopted  this  method  47  times,  and  among  42  uncompli- 
cated cases  there  were  only  three  recurrences.  In  many  cases  the 
adhesions  extend  up  into  the  sciatic  notch,  and  the  completion  of 
the  operation  may  be  difficult.  Best  exposure  is  secured  by  splitting 
the  fibers  of  the  gluteus  maximus  at  the  level  of  the  great  sacrosciatic 
foramen. 

Tic  Convulsif  or  Spasmodic  Tic  is  a  form  of  neuralgia,  usually  not 
painful,  characterized  by  constant  and  often  severe  twitching  in  the 
muscles  supplied  by  the  affected  nerves.  In  the  neck,  which  is  its 
most  frequent  seat,  it  produces  spasmodic  torticollis  (Fig.  653);  it  also 
occurs  in  the  face,  the  shoulder,  and  very  rarely  in  other  parts  of  the 
body.  Myotomy,  neurectasis,  neurotomy,  and  neurectomy  have  been 
employed,  but  the  disease  always  recurs  in  other  muscles,  no  matter 
how  wide  the  primary  nerve  excision  may  have  been.  Some  neurolo- 
gists go  so  far  as  to  maintain  that  even  were  the  cortical  centers 
governing  the  region  to  be  excised,  neighboring  centers  would  take 
on  diseased  action.  At  present  cure  of  the  disease  seems  hopeless 
by  operation,  though  the  temporary  improvement  usually  secured  is 
not  to  be  despised. 

Tumors  of  Nerves.  —  Fibrous  out-growths  occur  on  the  ends  of 
nerves  in  an  amputation  stump  ("amputation  neuromas"),  appar- 
ently due  to  attempts  at  regeneration:  the  nerve  fibers  turn  back 
upon  themselves,  being  unable  to  make  headway  forward,  and  form 
bulbous  masses;  if  these  are  caught  in  the  scar  they  are  painful,  and 
usually  have  a  strong  tendency  to  recur  if  excised,  or  even  after  formal 
re-amputation.  Such  growths  are  rare  except  where  the  amputation 
was  a  bungling  operation.  Multiple  tumors  occasionally  are  formed 
along  nerve  trunks  or  at  the  terminations  of  nerve  fibrils  in  the  skin 
(Fig. 58) .  This  disease  is  variously  known  as  multiple  neuro-fibromutosis 
(when  confined  to  nerve  trunks);  von  Recklinghausen's  disease  (1881)  or 
molluscum  fibrosum  (when  occurring  in  the  skin);  and  Rankenneurom 
or  plexijorm  neuroma,  which  occurs  in  the  form  of  a  circumscribed  thick- 
ening of  the  skin,  due  to  out-growth  of  nerve  fibrils — a  condition  most 
often  found  in  the  neck  or  scalp,  sometimes  pigmented,  and  usually 
congenital.  Da  Costa  (1910)  compares  the  condition  of  nerves  in  a 
plexiform  neuroma  to  that  of  the  arteries  in  a  cirsoid  aneurysm.  This 
disease,  in  its  various  forms,  usually  has  been  considered  a  form  of  dif- 
fuse fibromatosis,  blastomatoid  in  character;  but  in  the  second  edition 
of  his  Pathology  (1910)  Adami  returned  to  v.  Recklinghausen's  original 
theory,  and  to  that  of  Klebs  (1889),  which  lately  has  received  support 
from  other  observers,  that  these  growths  originate  in  the  nerve 
fibrils  themselves,  and  should  be  classed  as  Neurinomas.  Excision 
of  one  or  several  of  the  multiple  growths  may  be  required  for  pain  or 
deformity:  those  on  the  nerves  sometimes  may  be  shelled  out  with- 
out destroying  the  continuity  of  the  nerve  trunk.  The  "plexiform 
neuroma"  sometimes  recurs  after  removal;  sarcomatous  changes  may 
occur,  though  they  are  not  very  frequent. 


CHAPTER  XII. 


FRACTURES. 


The  study  of  fractures  is  one  of  the  most  important  subjects  which 
can  engage  a  surgeon's  attention;  they  are  injuries  which  occur 
constantly,  in  all  classes  of  life,  and  under  all  circumstances.  Even 
a  general  practitioner  cannot  avoid  having  a  number  of  cases  under 
his  care  every  year;  and  no  cases 
contribute  as  much  to  the  fame 
or  discredit  of  the  man  who  treats 
them.  And  while  it  is  well  recog- 
nized that  the  most  skilful  and 
assiduous  treatment  cannot  in 
all  cases  succeed  in  giving  the 
patient  a  useful  and  comely 
limb,  yet  it  is  sadly  true  that 
many  of  the  bad  results  con- 
stantly seen  are  due  to  sheer 
ignorance  and  neglect  on  the 
part  of  the  practitioner. 

Classification. — Fracture  of  a 
bone  may  be  complete  or  incom- 
plete. The  latter  form  (green- 
stick  fracture)  occurs  almost 
exclusively  in  young  children, 
the  bone  fibers  in  the  line  of 
extension  (convexity)  being  com- 
pletely ruptured,  while  those  in 
the  line  of  flexion  (concavity) 
maintain  their  continuity  (Fig. 
312). 

Fractures  may  be  subcuta- 
neous (simple)  or  open  (com- 
pound), the  latter  term  implying 
that  the  seat  of  fracture  com- 
municates with  the  external  air 
through  a  wound  of  the  soft 
parts. 

Comminuted  fractures  are  those  with  more  than  two  fragments,  the 
lines  of  fracture  intercommunicating  (Fig.  313).  They  are  to  be  dis- 
tinguished from  double  (triple,  quadruple,  etc.)  fractures  in  which  two 
(or  more)  separate  and  distinct  breaks  are  present  in  the  same  bone. 

(327) 


Fig.  312. — Green-stick  fracture  of  radius 
and  ulna  with  extreme  deformity.  Penn- 
sylvania Hospital. 


328 


FRAcrr/.-i-s 


Multiple  fracture  (Fig.  314)  is  a  term  which  should  be  reserved  for 
cases  with  breaks  in  more  than  one  bone,  the  bones  ail'eeted  not  being 
parallel  (like  the  ribs,  those  of  the  forearm,  the  leg,  hand,  etc.). 

Complicated  fractures  are  those 
attended  by  some  other  serious 
injury  of  the  .same  pari,  as  rupture 
of  the  main  bloodvessels,  crushing 
of  nerves,  dislocation  of  neighbor- 
ing joint,  etc.  A  fracture  of  the 
lower  end  of  the  femur  may  be  com- 
plicated by  a  fracture  of  the  skull, 
or  by  a  stab  wound  of  the  lung,  but 
such  a  fracture  is  not  a  "compli- 
cated fracture  of  the  femur"  un- 
less the  popliteal  artery  is  ruptured, 
the  knee-joint  dislocated,  or  some 
other  serious  injury  exists  in  the 
immediate  neighborhood  of  the 
fracture. 


Fig.  313. — Comminuted  fracture  of 
tibia  and  fibula,  a  few  hours  after  in- 
jury.    Episcopal  Hospital. 


Fig.  314. — Multiple  fracture  of  upper 
extremity.     Episcopal  Hospital. 


Direction. — Fractures  are  further  classified  as  longitudinal,  trans- 
verse, oblique,  spiral,  etc.  These  terms  are  self-explanatory  and  are 
illustrated  in  the  accompanying  skiagraphs  (Figs.  315,  316,  317). 
Transverse  fractures   are  more   frequent  in  cancellous  bone,  and  are 


CLASSIFICATION 


:il»'.i 


often  due  to  avulsion  of  the  bone  end  by  hyperextension  of  the  joint; 
occurring  in  the  shafts  of  long  bones  they  are  due  usually  to  direct 
violence;  whereas  oblique  and  spiral  fractures,  seen  almost  exclusively 
in  the  shafts  of  the  long  bones,  generally  are  due  to  a  twisting  force 
transmitted  ^from  a  distance;  and  longitudinal  fractures,  frequently 
extending  into  a  joint,  usually  are  caused  by  a  splitting  action.  They 
are  seen  oftenest  in  the  head  of  the  radius  or  tibia.  A  depressed 
fracture  is  one  seen  almost  exclusively  in  the  skull,  in  which  the 
fragments  are  displaced  by  the  vulnerating  force  below  the  level  of 
the  surrounding  bone.  An 
impacted  fracture  is  one  in 
which  one  fragment  is  driven 
into  the  other,  and  remains 
fixed  (Fig.  412).  Subperios- 
teal fracture  is  one  in  which 
the  periosteum  wholly  or  in 
great  part  remains  unrup- 
tured. 

Epiphyseal  Separations.  — 
The  epiphyses,  or  articular  ex- 
tremities of  the  long  bones, 
may  be  detached  from  the 
shafts  (diaphyses)  by  separa- 
tion along  the  epiphyseal  line 
until  the  age  when  ossifica- 
tion is  complete  in  the  car- 
tilage which  unites  epiphysis 
with  diaphysis.  The  injury 
is  most  common  at  the  lower 
ends  of  the  humerus,  radius, 
and  femur;  it  is  seen  also,  but 
more  rarely,  at  the  upper  ends 
of  the  humerus,  femur,  and 
tibia,  and  at  the  lower  end 
of  the  tibia.  The  injury, 
in  all  its  aspects,  so  closely 
resembles  a  fracture,  as  to 
be  considered  by  common 
consent  along  with  such  in- 
juries. 

Mechanism.  —  Bones  may 
be  broken  in  four  different 
ways:  (1)  by  torsion;  (2)  by 

flexion;  (3)  by  distraction,  and  (4)  by  compression.  For  a  bone  to  be 
broken  by  torsion,  it  is  necessary  for  one  of  its  ends  to  be  free,  while 
the  other  is  fixed;  the  injury  always  is  indirect,  and  the  line  of  fracture 
usually  oblique  or  spiral.  When  a  bone  is  broken  by  flexion,  the  force 
may  be  either  direct  or  indirect.    All  fractures  by  distraction  are  due 


Fig.  315. — Longitudinal  (splitting)  fracture  of 
tibia  and  fibula  (involving  knee-joint).  Age, 
forty  years.    Episcopal  Hospital. 


330 


FRACTURES 


to  indirect  violence,  and  practically  all  produced  by  compression  result 
from  direct  violence. 

Causes  of  Fracture. — Predisposing  Causes. — These  arise  either  from 
the  condition  of  the  patient  or  that  of  the  bone  affected.  Bones  of 
the  aged  are  more  liable  to  fracture,  because  more  brittle,  than  those 
of  young  persons;  but  as  the  latter  lead  more  active  lives,  and  are 
more  exposed  to  exciting  causes,  the  number  of  fractures  actually 
occurring  in  the  aged  is  less  than  in  the  young.    Likewise  the  male 


Fig.  316. — Transverse  serrated  fracture  of 
humerus.     Episcopal  Hospital. 


Fig.  317. — Oblique  and  spiral  frac- 
ture of  femur.  Age  three  years. 
Episcopal  Hospital. 


sex,  from  its  greater  exposure,  is  more  liable  to  fracture  than  the 
female.  Certain  diseases  of  bones  render  them  more  liable  to  be 
broken,  especially  osteopsathyrosis  and  malignant  growths.  The 
situation  of  a  bone  may  predispose  it  to  fracture,  the  clavicle  being 
more  often  broken  than  the  scapula,  the  lower  than  the  upper  jawT, 
etc. ;  and  the  function  of  a  bone  has  a  predisposing  influence,  the  bones 
of  the  extremities  being  broken  more  often  than  those  of  the  trunk. 

Exciting  Causes. — Fractures  may  occur  at  the  point  of  impact, 
from  direct  violence  (gunshot,  cart  wheel,  falling  brick,  etc.);  or  may 


SYMPTOMS  OF  FRACTURES  331 

be  due  to  transmitted  force  {indirect  violence),  as  fracture  of  the 
elbow  from  falls  on  the  hand. 

Fracture  by  muscular  action  usually  is  a  variety  of  fracture  from 
indirect  violence,  one  end  of  a  long  bone  being  twisted  violently 
by  the  muscles  attached  to  it,  and  being  wrenched  loose,  as  it  were, 
from  the  other  end,  which  opposes  its  inertia  to  the  sudden  muscular 
impulse;  this  is  the  explanation  of  fractures  of  the  humeral  shaft 
from  throwing  a  ball  (Ashhurst,  1905).  Muscular  action  may  tear  off 
an  apophysis  (coracoid  process,  greater  tuberosity  of  humerus,  anterior 
superior  iliac  spine,  etc.),  or  may  break  the  patella  or  olecranon  by 
sudden  flexion  over  their  neighboring  condyles,  as  an  over-bent  lever. 

Sprain  fracture  (Callender,  1870)  is  due  to  separation  of  a  ligament 
from  its  point  of  insertion,  with  detachment  of  a  small  shell  of  bone. 

Spontaneous  or  Pathological  Fractures  are  those  due  to  preexisting 
bone  disease,  where  trauma  is  minimal,  as  in  fragilitas  ossium, 
secondary  carcinoma  of  bone,  etc.    . 

Symptoms  of  Fractures. — In  addition  to  a  history  of  injury,  which 
exists  in  all  cases  except  some  pathological  fractures,  there  are  both 
symptoms  and  physical  signs  by  which  a  diagnosis  of  fracture  can  be 
made  clinically,  with  very  few  exceptions;  in  such  exceptional  cases 
the  use  of  the  a>ray  nearly  invariably  will  reveal  the  true  nature  of 
the  lesion. 

Pain  and  Tenderness.- — These  are  present  in  practically  every  case 
and  are  by  no  means  proportionate  to  the  apparent  degree  of  injury, 
some  very  severe  compound  comminuted  fractures  causing  the  patient 
less  discomfort  than  a  single  subcutaneous  break.  When  no  other 
physical  signs  are  present,  the  surgeon  should  always  suspect  a  fracture 
when  there  exists  persistent  localized  tenderness  of  a  bone,  following 
injury;  such  a  fracture  may  be  subperiosteal  or  impacted,  and  the 
surgeon  should  treat  such  a  case  as  one  of  fracture  until  the  incorrect- 
ness of  his  diagnosis  has  been  proved. 

Swelling,  Ecchymosis,  etc.,  are  present  to  some  degree  in  nearly 
all  cases  of  fracture  (Fig.  318),  owing  to  coincident  injury  of  the  soft 
parts;  but  they  have  no  special  significance.  Abrasion  over  the  seat  of 
fracture  usually  shows  that  the  break  is  due  to  direct  violence. 

Deformity  or  Displacement. — This  is  one  of  the  most  constant  and 
valuable  signs  of  fracture.  It  may  be  due  either  (1)  to  the  fracturing 
force,  or  may  occur  subsequently  (2)  from  muscular  action;  both 
these  factors  may  be  operative;  or  finally  it  may  be  caused  simply 
(3)  by  the  weight  of  the  limb. 

1 .  Deformity  from  the  fracturing  force  is  seen  best  in  impacted  and 
in  depressed  fractures.  In  fractures  with  great  displacement  other 
factors  as  well  usually  are  at  work. 

2.  Deformity  from  muscular  action  is  seen  especially  in  the  long 
bones  of  the  extremities,  and  occurs  most  markedly  when  the  fracture 
is  close  above  or  below  the  attachment  of  powerful  muscles — as 
above  or  below  the  insertion  of  the  deltoid,  below  the  insertion  of 
the  iliopsoas  tendon,  above  the  origin  of  the  gastrocnemius,  etc.    In 


332 


FRACTURES 


fractures  of  the  patella  and  olecranon  it  is  almost  the  only  cause 
of  deformity.  It  is  responsible  both  for  the  shortening,  and  for  the 
angular  deformity,  as  well  as  for  many  cases  of  rotatory  displacement. 
Deformity  from  muscular  action  is  dependent  in  part  on  the  natural 
tension  of  the  muscles,  in  part  on  involuntary  contraction  (spasmodic) 
from  reflex  nervous  action,  and  in  part  on  voluntary  action  by  the 
patient. 

o.  Deformity  from  the  force  of  gravity  is  seen  in  the  outward  rotation 
of  the  leg  which  occurs  in  fractures  of  the  femur;  in  the  deformity 
known  as  "loss  of  the  carrying  angle"  in  supracondylar  fractures 
of  the  humerus;  in  the  dropping  of  the  shoulder  in  fractures  of  the 
clavicle,  etc. 


Fig.  31S. — Ecchymosis  twenty-four  hours  after  fracture  of  surgical  neck  of  humerus, 
extravasation  occurring  in  course  of  long  tendon  of  biceps.     Episcopal  Hospital. 

Direction  of  Displacement. — This  may  be  longitudinal,  lateral, 
angular,  or  rotatory. 

1.  Longitudinal  displacement  almost  always  consists  in  shortening; 
lengthening  is  seen  only  in  fractures  of  the  olecranon  and  patella,  and 
in  some  of  the  calcaneum;  in  fracture  of  the  lower  end  of  the  fibula, 
lengthening  of  this  bone  may  occur  from  inward  rotation  of  the  foot 
(Malgaigne,  1841).  If  the  fracture  is  transverse,  there  can  be  no 
marked  shortening  unless  there  has  first  been  lateral  displacement, 
as  the  amount  of  shortening  which  occurs  in  an  impacted  fracture 
rarely  exceeds  one  or  two  centimeters;  oblique  fractures,  however, 
permit  of  great  shortening  without  much  lateral  displacement.  If  the 
ends  of  the  fragments  are  displaced  so  far  as  to  pass  by  one  another, 
overlapping  is  said  to  exist,  the  more  prominent  fragment  overriding 


SYMPTOMS  OF  FRACTURES  333 

the  less  prominent.  In  fractures  of  the  femur  the  shortening  from 
overlapping  may  be  from  5  to  10  centimeters.  In  many  fractures 
it  is  requisite,  and  in  most  it  is  highly  desirable,  to  take  the  actual 
measurements  of  the  sound  and  injured  limb  between  known  fixed 
points  to  determine  whether  or  not  there  is  shortening,  and  not  to 
rely  on  the  evidence  of  the  eyes  alone  to  determine  this  point. 

2.  Lateral  or  transverse  displacement  has  been  mentioned  already; 
it  occurs  mostly  in  transverse  fractures,  and  when  marked  allows 
overlapping. 

3.  Angular  deformity  usually  results  from  the  fracturing  force.  This 
is  well  seen  in  cases  of  green-stick  fracture  (Fig.  312);  but  it  may 
be  originally  caused  by  muscular  action,  and  usually  is  maintained 
by  this  or  by  the  force  of  gravity. 

4.  Rotatory  displacement  consists  in  the  fragments  being  twisted  on 
their  own  axis  in  opposite  directions,  either  from  muscular  action  or 
the  force  of  gravity.  In  fractures  of  the  radius  above  the  insertion 
of  the  pronator  radii  teres  the  upper  fragment  is  snpinated  by  the 
biceps,  while  the  lower  is  pronated  by  the  pronator  teres;  in  fractures 
of  the  neck  of  the  femur  the  lower  fragment  is  rotated  outward  by 
the  force  of  gravity  and  the  external  rotator  muscles,  which  are 
more  powerful  than  the  internal  rotators. 

Displacement  may  not  be  due  to  fracture,  but  to  some  other  lesion. 
Dislocations,  old  joint-diseases,  exostoses,  as  well  as  other  affections, 
may  cause  deformity  with  shortening,  angularity,  or  rotation;  so 
the  surgeon  must  not  place  reliance  upon  deformity  alone  in  the 
diagnosis  of  fracture. 

Mobility. — Preternatural  mobility  in  a  bone,  following  recent  injury, 
implying  as  it  does  motion  at  some  point  other  than  the  joints,  is 
almost  pathognomonic  of  fracture;  but  the  normal  flexibility  of  some 
bones  (ribs,  fibula,  rachitic  bones)  should  not  be  mistaken  for  abnormal 
mobility.  In  some  cases  mobility  is  so  great  that  it  is  evident  at  a 
glance,  the  limb  swinging  flail-like  at  the  site  of  fracture;  in  others, 
especially  where  only  one  of  two  or  more  parallel  bones  is  broken 
(ribs,  metacarpals,  etc.),  mobility  may  be  difficult  to  detect.  In 
subperiosteal  and  impacted  fractures  it  is  entirely  absent;  and  in 
other  forms  of  fracture  it  may  be  impossible  to  detect  it  owing  to  the 
depth  at  which  the  bone  lies,  existence  of  swelling,  etc.  In  fractures 
close  to  a  joint,  and  in  those  in  which  the  line  of  fracture  is  wholly 
or  in  part  intra-articular,  no  mobility  may  be  demonstrable.  While  in 
a  fracture  a  false  point  of  motion  exists,  in  a  dislocation  the  mobility 
of  the  affected  joint  is  diminished. 

Crepitus. — Crepitus  is  a  term  used  to  describe  the  grating  sensation 
appreciable  by  palpation  and  frequently  also  by  auscultation  (a 
stethoscope  may  be  used),  when  the  ends  of  the  fragments  are  moved 
against  each  other.  When  present  in  connection  with  mobility,  the 
diagnosis  may  be  considered  established.  Crepitus  should  not  be 
mistaken  for  the  creaking  of  tenosynovitis,  nor  for  the  similar  sound 
produced  by  motion  of  some  diseased  joints;  nor  yet  for  the  crackling 


334  FRACTURES 

of  subcutaneous  emphysema.  Crepitus  may  be  absent,  owing  to 
the  ends  of  the  fragments  not  being  in  contact  (overlapping,  separa- 
tion),  or  to  muscular  or  fibrous  tissues  intervening;  in  green-stick, 
impacted,  and  subperiosteal  fractures,  there  is  no  crepitus. 

Loss  of  Function  is  another  valuable  sign  of  fracture,  though  it  is 
by  no  means  universally  present.  Patients  with  fracture  of  the 
fibula  may  continue  at  work,  and  apply  for  treatment  only  because 
of  deformity  or  persistent  disability;  the  same  is  true  of  fractures 
of  the  ribs;  and  of  some  fractures  in  which  pain  is  absent  owing  to 
nerve  lesions,  or  in  which  it  is  not  appreciated  owing  to  the  develop- 
ment of  mania  a  potu,  etc. 

Circumstantial  Evidence  of  fracture,  in  addition  to  the  above  men- 
tioned direct  signs,  is  afforded  by  various  occurrences:  subcutaneous 
emphysema  corroborates  a  diagnosis  of  fracture  of  the  nasal  bones, 
discharge  of  cerebrospinal  fluid  from  the  ear  indicates  a  fracture  of 
the  middle  fossa  of  the  skull,  etc. 

Diagnosis  of  Fracture. — If  a  surgeon  conscientiously  and  system- 
atically examines  the  patient  there  should  be  very  few  cases  in  which 
the  existence  or  non-existence  of  fracture  remains  doubtful.  Inquiry 
should  be  made  as  to  the  history  of  the  accident,  including  the  mode 
of  injury,  the  position  of  the  patient,  whether  the  lesion  is  due  to  a 
fall  of  the  patient,  or  to  his  being  struck  by  another  body.  If  he  fell, 
it  should  be  ascertained,  if  possible,  how  he  landed — whether  on  the 
outstretched  hand,  whether  his  foot  turned  in  or  out,  whether  his 
knee  suddenly  flexed  or  became  hyperextended,  whether  his  arm  was 
abducted  or  lay  across  the  thorax,  etc.  Occasionally  when  a  bone 
breaks  a  crack  is  heard. 

Inspection. — Inspection  may  show  the  patient  supporting  or  pro- 
tecting the  injured  part,  may  reveal  evident  deformity,  shortening, 
abrasion,  swelling,  etc. 

Palpation. — Running  the  fingers  lightly  along  the  surface  of  the 
suspected  bone,  the  point  of  greatest  tenderness,  nearly  always 
corresponding  to  the  site  of  fracture,  can  soon  be  determined.  Sup- 
porting one  end  of  the  injured  bone  gently  but  firmly  in  each  hand, 
test  is  then  made  for  abnormal  mobility,  by  attempting  to  increase 
or  decrease  angular  deviation  of  the  fragment,  or  to  rotate  one 
fragment  on  the  other.  In  fractures  near  joints,  lateral  mobility, 
where  none  is  normally  present  (elbow,  knee)  may  thus  be  detected 
(in  dislocations  there  is  immobility  rather  than  abnormal  mobility). 
In  most  cases  crepitus  will  be  elicited  during  the  manoeuvres  advised 
for  detection  of  mobility,  but  where  overlapping  exists  it  may  be 
necessary  first  to  bring  the  fractured  ends  into  apposition;  when 
crepitus  once  has  been  detected  it  is  reprehensible  to  make  attempts 
at  reproducing  it  merely  for  the  edification  of  bystanders. 

Mensuration.  —  Mensuration  has  been  mentioned  already  as  a 
valuable  means  of  detecting  shortening.  In  the  upper  extremity 
the  fixed  points  employed  are  the  tip  of  the  acromion  or  the  met- 
acromial  tubercle,  the  condyles  of  the  humerus,  and  the  styloid  proc- 


SKIAGRAPHY  335 

esses  of  the  radius  and  ulna;  in  the  lower  extremity  measurements 
are  made  from  the  anterior  superior  iliac  spine  or  symphysis  pubis 
to  either  of  the  malleoli;  or  to  the  lower  border  of  the  patella,  head 
of  the  fibula,  etc.  By  placing  the  corresponding  limbs  in  similar 
attitudes  and  taking  repeated  and  accurate  measurements,  the  pres- 
ence of  shortening  usually  can  be  ascertained.  It  should  not  be 
forgotten,  however,  that  in  many  persons  the  two  lower  extremities 
normally  are  not  of  equal  length. 

It  is  important  to  make  a  correct  diagnosis  and  to  institute  proper 
treatment  as  soon  as  possible  after  the  injury  is  received;  deformity 
at  first  easily  appreciable  may  soon  be  obscured  by  swelling,  and 
not  only  will  the  diagnosis  then  be  more  difficult  than  if  made  at 
first,  but  reduction  of  the  deformity  and  other  proper  treatment 
will  be  less  effectual  or  even  impossible  if  the  case  is  not  seen  early. 
In  all  cases,  moreover,  in  which  fracture  is  suspected,  the  case  should 
be  treated  as  if  fracture  were  present  until  the  contrary  is  proved. 

Skiagraphy. — Skiagraphy  is  a  great  aid  in  confirming  a  diagnosis 
of  fracture  tentatively  made,  or  in  disproving  its  existence  when 
one  is  suspected.  Whenever  possible  a  skiagraph  should  be  made 
before  the  patient  is  examined,  as  a  matter  of  record;  and  usually  it  is 
desirable  for  the  surgeon  to  examine  the  plate  before  treatment  is 
instituted.  Certainly  after  reduction  has  been  attempted  it  is  wTell 
for  him  to  have  ocular  evidence  of  what  he  has  accomplished;  and 
if  reduction  is  not  satisfactory  he  can  try  again.  In  making  radio- 
graphs the  film  side  of  the  plate  is  placed  next  the  patient's  limb, 
and  the  picture  etched  on  the  plate  is  the  shadow  of  those  parts 
impervious  to  the  .r-rays.  In  looking  at  the  developed  plate,  if  it 
is  held  with  the  film  side  toward  the  observer,  he  is  in  the  position 
occupied  by  the  Crookes  tube  when  the  exposure  was  made,  and, 
therefore,  is  looking  at  the  shadows  of  the  bones  from  the  side  of 
exposure.  In  taking  lateral  views  of  the  limbs,  that  bone  or  portion 
of  bone  nearest  the  plate  when  the  exposure  was  made,  will  be  most 
clearly  defined. 

Skiagraphs  often  are  very  deceptive.  For  instance,  if  the  bones  overlap, 
and  lie  in  the  same  axis,  a  skiagraph  which  superposes  one  shadow 
on  the  other  may  show  no  fracture;  one  which  is  taken  in  the  same 
plane  as  that  in  which  angular  displacement  occurs,  may  show  no 
deformity.  Hence  it  is  a  good  rule  always  to  have  two  plates 
made,  exposure  being  in  planes  at  right  angles  to  each  other.  If  the 
Crookes  tube  is  too  close  to  the  limb  its  rays  will  be  quite  divergent 
when  impinging  on  the  skiagraphic  plate,  and  all  the  shadows  will 
be  exaggerated;  and  the  further  a  bone  lies  from  the  plate  the  more 
rays  it  will  intercept  and  the  larger  its  shadow  will  appear.  If  the 
Crookes  tube  is  not  accurately  centered  over  the  fracture,  the  shadows 
cast  by  the  fractured  ends  will  be  much  distorted,  perhaps  markedly 
exaggerating  the  deformity,  amount  of  callus,  etc.  In  passing  judg- 
ment upon  a  skiagraph,  therefore,  it  is  important  to  take  these  points 
into  consideration,  and  not  to  regard  as  evidence  of  malpractice 
phenomena  which  may  be  quite  easily  explained  in  other  ways. 


336 


FRACTURES 


Prognosis  of  Fracture. — Prognosis  as  to  life  is  good.  In  large 
scries  of  statistics  the  general  mortality  from  fractures  is  about  2.5  per 
cent.  Compound  and  complicated  fractures  have  a  higher  mortality. 
.Multiple  fractures,  as  I  pointed  out  in  1907,  in  studying  240  cases, 
give  a  mortality  of  about  25  per  cent.,  even  when  deaths  occurring 
soon  after  the  injury  from  hemorrhage,  shock,  visceral  injuries,  etc., 
are  excluded.  In  general  it  may  be  said  that  the  chief  causes  of 
death  in  fractures  of  any  variety  are  visceral  diseases  (pneumonia, 
uremia),  delirium  tremens,  and,  in  the  aged,  exhaustion. 

The  prognosis  as  to  the  function 
of  the  fractured  part  depends  more 
upon  treatment  than  any  other  single 
factor.  As  a  rule,  function  is  more 
quickly  and  completely  restored  in 
children  and  young  adults  than  in  the 
aged;  and  in  those  of  sound  constitu- 
tion than  those  with  rheumatic  or 
gouty  tendencies. 

Process  of  Union  in  Fractured 
Bones. — It  has  been  entirely  too 
much  the  custom  to  regard  bones  as 
so  many  sticks  or  pieces  of  stone  em- 
bedded in  the  soft  tissues.  The  stu- 
dent should  disabuse  himself  of  this 
idea,  and  should  aim  constantly  to 
remember  that  bone  is  a  living  tissue, 
composed  of  cells  and  intercellular 
substance,  and  differing  chiefly  in  the 
composition  of  the  latter  from  other 
tissues  such  as  muscle  or  epithelium. 
Bone  reacts  to  injury  or  disease  in 
very  much  the  same  way  as  other 
tissues;  the  phenomena  of  inflamma- 
tion and  repair  may  appear  less  active 
and  slower  than  in  the  soft  tissues, 
but  they  are  none  the  less  present.  A 
glacier  is  a  fluid  body,  though  it  looks 
solid ;  it  flows  slowly  and  invisibly,  but 
none  the  less  surely;  so  with  bone: 
processes  measured  by  minutes  or 
hours  in  soft  structures  may  take  days  or  weeks  in  bone,  but  they 
are  the  same  in  kind. 

\\  hen  a  bone  is  broken,  the  surrounding  soft  parts  are  more  or  less 
damaged,  and  themselves  react  to  the  injury  by  the  process  of  inflam- 
mation as  described  in  Chapter  I.  A  certain  amount  of  blood  is 
extravasated  between  the  ends  of  the  broken  bone,  and  the  various 
cellular  elements  of  the  tissues  in  the  injured  area  (bone  cells  from 
the   marrow   and  periosteum,   muscle   cells,   connective    tissue   cells, 


Fig.  319.  ■ —  Skiagraph  showing 
callus  several  weeks  after  fracture  of 
radius.     Episcopal  Hospital. 


PROCESS  OF   UNION  IN  FRACTURED  BONES 


661 


leukocytes,  etc.),  proliferate,  and  aid  in  removing  debris  and  causing 
organization  in  the  mass  of  inflammatory  lymph  which  is  formed. 
The  intercellular  substance  of  the  bone  is  temporarily  absorbed  or 
removed  from  the  fractured  ends  by  osteoclasts,  and  the  exudate 
forming  between  the  fragments,  which  is  known  as  callus,  is  strictly 
analogous  to  the  inflammatory  lymph  which  surrounds  it  and  with 
which  it  is  continuous.  The  ends  of  the  fragments  thus  become  soft 
and  sticky,  and  may  be  compared  to  the  ends  of  a  broken  stick  of 
scaling  wax  which  one  seeks  to  weld  together  again  after  heating  in 
a  flame.  This  callus  is  derived  largely  from  the  medulla  of  bono,  by 
proliferation  of  osteoblasts.     This  portion  of  it  is  known  as  interior 


Fig.  320. — Skiagraph  of  exuberant  callus  from  fractures  of  elbow  and  forearm. 


or  pin-callus,  while  that  portion  formed  from  the  periosteum  is  known 
as  ensheathing  or  ring-callus;  the  material  lying  between  the  ends  of 
the  compact  substance  of  the  bone  is  known  as  the  permanent  or 
definitive  callus  as  distinguished  from  the  pin-  and  ring-callus,  which 
is  called  provisional  or  temporary  callus. 

In  the  course  of  ten  days  or  two  weeks  the  callus  becomes  impreg- 
nated with  lime  salts,  often  passing  through  a  cartilaginous  stage; 
and  the  bone  can  no  longer  be  freely  bent  at  the  seat  of  union  (Fig. 
319).  The  callus  gradually  becomes  condensed  as  organization  pro- 
ceeds and  remains  only  as  a  slight  thickening  at  the  site  of  previous 
fracture;  but  the  pin-callus  usually  is  not  entirely  absorbed,  and 
complete  restoration  of  the  medullary  canal  is  rare.  If  there  has  been 
22 


338  FRACTURES 

exuberant  outpouring  of  callus  (Fig.  320),  it  may  cause  union  between 

adjoining  bones,  may  interfere  with  full  flexion  or  extension  of  a 
joint,  may  limit  rotation  in  the  forearm,  may  grow  around  nerves  or 
tendons,  or  cause  injurious  pressure  on  them  or  on  vascular  channels, 
resulting  in  trophic  changes,  edema,  etc. 

If  the  fracture  is  subperiosteal  the  amount  of  ring-callus  formed 
will  be  inappreciable;  and  the  less  the  primary  displacement  and 
the  more  accurate  the  reduction  of  the  fractured  ends,  the  less  will 
be  the  amount  of  the  ring-callus.  In  fractures  of  the  skull  or  ribs, 
and  in  impacted  fractures,  where  displacement  is  slight,  no  appreci- 


Fig.  321. — Skiagraph  of  supracondylar  fracture  of  humerus,  showing  new-formed  bone 
beneath  bridge  of  periosteum,  three  weeks  after  injury.    Episcopal  Hospital. 

able  callus  is  formed.  If  the  periosteum  is  stripped  up  from  the  shaft 
of  a  bone  blood-clot  will  form  beneath  it,  as  well  as  between  the 
broken  ends,  and  becoming  organized  will  cause  thickening  of  the 
shaft,  as  the  periosteum  will  be  unable  to  fall  back  into  its  normal 
position  (Fig.  321).  The  periosteum  is  rarely  completely  detached 
from  the  broken  ends,  usually  remaining  at  least  on  one  side  as  a 
periosteal  bridge  (Oilier,  1867),  which  may  secure  firm  bony  union 
even  in  cases  where  marked  displacement  persists. 

The  process  described  above  usually  does  not  make  its  beginning 
manifest  for  several  days  after  the  occurrence  of  fracture,  and  is 


TREATMENT  OF  SIMPLE  FRACTURES  339 

longer  delayed  in  comminuted  and  in  compound  than  in  simple 
fractures.  In  multiple  fractures  it  is  a  very  usual  thing  for  one  or 
two  fractures  to  unite  in  the  ordinary  time,  and  for  the  other  fractures 
to  remain  ununited  until  those  first  uniting  are  quite  firm,  when 
union  may  commence  in  the  remaining  fractures.  In  simple  fractures 
fairly  firm  union  is  present  at  the  end  of  two  weeks,  though  at  this 
time,  and  in  larger  bones  for  some  weeks  afterward,  bending  at  the 
seat  of  fracture  still  may  occur.  An  adult's  femur  requires  usually 
eight  or  ten  weeks  for  absolutely  firm  union  to  occur.  It  is  said  that 
in  no  fracture  is  the  structure  of  the  bone  entirely  restored  until  a 
year  after  the  accident. 

Delayed  union  is  a  relative  term,  since  no  fixed  limits  can  be  set 
within  which  union  should  be  firm.  If  union  has  not  occurred  at  the 
end  of  ten  or  twelve  weeks,  it  is  usual  to  regard  the  case  as  one  of 
Non-union  or  Ununited  Fracture.  In  these  cases  the  tissue  between 
the  fragments  remains  in  a  fibrous  condition,  no  bone  salts  being 
deposited. 

Treatment  of  Fractures. — The  general  principles  already  inculcated 
as  proper  in  the  treatment  of  inflammation  guide  the  surgeon  in  the 
treatment  of  fractures.  The  indications  are  to  replace  the  broken 
bones  in  proper  position,  with  due  regard  for  the  condition  of  the  soft 
parts,  to  maintain  the  fragments  in  proper  position,  and  to  dress  the 
injured  part  at  suitable  intervals  until  cure  is  complete. 

Treatment  of  Simple  Fractures. — Fractures  often  are  received  at 
a  distance  from  the  patient's  home  or  a  surgeon,  and  it  becomes 
necessary  to  transport  the  patient  to  a  place  where  the  injury  can 
be  treated.  The  fractured  limb  should  be  rendered  as  immobile  as 
possible;  this  may  be  accomplished  by  the  temporary  application 
of  any  available  support  (shingles,  canes,  umbrella  ribs,  bark  of 
trees,  twigs,  etc.),  applied  over  the  clothing  or  suitable  padding,  or 
even  by  wrapping  the  limb  firmly  in  clothing,  without  constriction; 
if  the  patient  is  unable  to  walk,  he  is  carried  on  a  shutter  or  on  a 
stretcher  improvised  from  poles  and  clothing,  to  his  home  or  the 
nearest  hospital.  Transport  splints  have  been  mentioned  in  connec- 
tion with  gunshot  wounds  (p.  204). 

1.  Reducing  the  Fracture.  This,  which  often  is  expressed  by  the 
term  "setting  the  bone,"  is  a  relative  term,  since  comparatively 
few  broken  bones  can  be  accurately  restored  to  their  original  form; 
and  in  the  case  of  shafts  of  long  bones  it  is  not  always  necessary 
that  reduction  should  be  accurate.  Nevertheless,  the  aim  must  be  to 
secure  as  accurate  reduction  as  possible,  and  in  the  case  of  fractures 
near  joints  (especially  the  elbow  and  ankle)  it  is  extremely  important 
to  do  so;  but  in  the  middle  of  the  shaft  of  a  long  bone  it  is  sufficient 
to  secure  firm  bony  union,  with  no  appreciable  shortening,  with  preser- 
vation of  the  normal  axis  of  the  limb,  and  without  rotation  of  one  frag- 
ment on  the  other.  For  the  first  and  second  results  to  be  obtained 
it  is  necessary  for  the  fragments  to  be  in  contact  "end-on,"  not  only 
by  lateral  contact;  and  for  the  lateral  displacement  not  to  exceed 


340 


FR ACT  IRES 


two-thirds  of  the  diameter  of  the  bone  (Figs.  322  and  323).  The  axis 
of  the  limb  sometimes  may  be  preserved  without  end-to-end  contact 
of  the  fragments,  but  it  is  very  rare  for  firm  union  to  be  seemed 
(except  in  children),  and  shortening  never  will  be  absent  unless 
overlapping  is  reduced. 

The  methods  of  securing  reduction  arc  many,  and  will  be  described 
when  the  injuries  of  the  individual  bones  are  discussed.  Jt  is  sufficient 
to  point  out  here  that  other  than  manual  force  seldom  is  necessary, 
it'  the  surgeon  takes  advantage  of  the  relaxation  of  die  muscles  which 
may  be  secured  by  position  of  the  limb;  sometimes  anesthesia  will 
be  necessary,  and  less  often  operative  intervention  (p.  343).  Secur- 
ing  muscular   relaxation    by   position,    the    surgeon    with    his    hands 


Fig.  322. — Showing  fragments  of 
broken  bone  in  contact  "end-on,"  and 
with  not  too  much  lateral  displacement 
or  firm  union. 


Fig.  323. — Fragments  displaced  later- 
ally and  with  angular  deformity;  contact 
not  sufficient  for  firm  union. 


makes  extension  and  counter-extension  on  the  broken  bone,  and, 
by  gently  but  firmly  applied  direct  pressure,  pushes  the  ends  of  the 
fragments  into  contact:  if  reduction  has  been  properly  secured, 
there  will  be  distinct  crepitus  as  the  broken  ends  come  together, 
the  normal  length  of  the  limb  will  be  restored,  and  bony  deformity 
will  disappear.  It  then  becomes  necessary  merely  to  maintain  reduc- 
tion until  union  is  sufficiently  firm.  In  many  cases  (femur,  tibia) 
gradual  reduction  may  be  secured  by  means  of  weight  extension  in  the 
course  of  a  few  days,  without  an  anesthetic,  even  when  primary  efforts 
to  secure  reduction  have  failed.  In  muscular  adults  some  form  of 
skeletal  traction  may  be  advisable;  this  is  traction  fixed  directly  to 
the  skeleton  at  some  point  below  the  fracture.  The  principle,  which 
appears  to  have  been  introduced  by  Codivilla  (1904),  was  popularized 


TREATMENT  OF  SIMPLE  FRACTrh'ES 


m 


by  Steinmann  I  LOO'S  I,  whose  "pins"  arc  passed  (by  boring  by  hand) 
through  the  femoral  condyles,  the  head  of  the  tibia,  or  the  calcaneum 
(Fig.  324).  RansohofT  ( L912)  and  Besley  (1918)  have  adapted  appa- 
ratus like  ordinary  ice-tongs  for  the  same  purpose. 

2.  Maintaining  the  Fragments  in  Apposition.  For  this  purpose  it 
is  usual  to  employ  splints  or  other  external  support,  held  in  place 
by  bandages,  plasters,  etc.  Splints  are  made  of  various  materials 
(wood,  tin,  wire,  gypsum,  etc.),  and  of  various  special  forms.  These 
will  be  described  when  discussing  fractures  of  the  several  bones. 
It  is  above  all  things  important  to  recognize  the  fact  that  splints 
are  not  used  for  the  purpose  of  overcoming  deformity,  but  merely 
to  maintain  the  limb  in  correct  position  after  the  deformity  has  been 
reduced.  The  action  of  splints  in  this  regard  may  be  much  assisted 
by  the  position  in  which  the  limb  is  dressed,  and  by  the  use  of  weight 


Fig.  324. — Steinmann  nail  extension  in  calcaneum.     Episcopal  Hospital. 


extension  to  overcome  spasmodic  muscular  contraction.  If  a  fracture 
is  close  to  a  joint  it  is  necessary  to  immobilize  the  joint  also;  in 
general  terms,  it  is  desirable  to  immobilize  so  much  of  the  limb  as 
will  prevent  any  lever  action  being  transmitted  to  the  site  of  fracture 
by  movement  of  the  portions  of  the  limb  left  free. 

Before  a  splint  is  applied  it  should  be  covered  smoothly  with  raw- 
cotton,  oakum,  or  some  similar  material  in  sufficient  amount  to  pre- 
vent painful  pressure  on  the  limb,  special  care  being  taken  to  protect 
bony  prominences,  superficial  nerves,  bloodvessels,  etc.  It  often  is 
well  to  apply  between  the  splint  and  its  padding,  and  over  the  ends 
of  the  fragments,  pads  suitable  to  prevent  recurrence  of  deformity, 
provided  no  pressure  is  exercised  which  might  injure  the  soft  parts. 
An  excellent  rule  is  never  to  apply  a  bandage  beneath  the  splints  around 
the  fractured  region:  in  all  fractures  there  is  more  or  less  injury  of 


342 


FRACTURES 


the  soft  parts,  ami  the  reactive  swelling  which  occurs  in  these,  has 
demonstrated  on  numerous  occasions  the  danger  to  which  the  patient 
is  subjected  by  neglect  to  observe  this  rule;  a  bandage  which  seems 
loose  enough  when  first  applied  may  in  a  very  few  hours  become  so 
tight  as  to  cause  serious  constriction,  perhaps  resulting  in  gangrene 
of  the  extremity.  Under  all  circumstances  it  is  well  to  leave  exposed 
the  tips  of  the  fingers  or  toes,  and  to  direct  the  nurse  or  the  members 


Fig.  325.  —  Compound  comminuted 
fracture  of  tibia  and  fibula  (bones  pro- 
truded through  skin  on  each  side  of  leg, 
and  were  "reduced"  by  family  physician 
after  applying  iodin  before  admission  to 
hospital) .  On  admission  in  fracture  box, 
shortening  3 .  5  cm. 


Fig.  326. — Two  weeks  after  nail  extens- 
ion (16  pounds).  Overlapping  reduced. 
Firm  union  secured.  Out  of  work  four 
months.     Episcopal  Hospital. 


of  the  patient's  family  to  examine  their  condition  at  frequent  intervals; 
should  any  interference  with  the  circulation  become  evident  the  dress- 
ings must  be  removed  at  once  and  be  re-applied  more  circumspectly. 

At  the  first  visit,  the  surgeon  should  proceed  to  examine  the  injured 
member  as  described  at  p.  334;  but  he  should  not  attempt  to  reduce 
the  fracture  until  he  has  all  his  dressings  prepared  for  application. 

3.  The  after-care  of  a  fractured  bone  involves"  removal  of  the 
dressing  frequently  enough  to  make  sure  that  the  soft  parts  are  in 


OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES         343 

good  condition,  and  that  reduction  is  maintained  by  the  dressing 
employed.  The  surgeon  never  should  neglect  to  see  the  patient  on 
the  day  after  the  dressing  is  first  applied,  and  to  ascertain  for  him- 
self that  the  limb  is  in  good  condition,  and  that  the  dressing  is  com- 
fortable; an  uncomfortable  dressing  always  is  inefficient  even  if  not 
positively  harmful;  but  if  the  dressing  is  comfortable  it  is  not  desirable 
to  re-dress  the  limb  more  than  two  or  three  times  weekly  at  first, 
and  less  often  as  union  progresses.  As  the  splints  and  bandages 
are  being  removed  for  re-dressing,  the  surgeon  should  support  the 
fractured  part  in  such  a  way  as  to  substitute  his  support  for  the 
splints,  preventing  dislocation  of  the  fragments,  and  rendering  dress- 
ing of  the  fracture  entirely  painless.  While  this  support  is  main- 
tained, the  patient's  skin  should  be  sponged  off  gently  with  dilute 
alcohol,  employing  such  gentle  friction  as  will  stimulate  the  circula- 
tion. I  do  not  approve  of  massage  or  mobilization  in  the  treatment 
of  fractures,  except  in  so  far  as  they  are  unavoidable  in  procuring 
proper  care  of  the  soft  parts;  and  while  I  acknowledge  the  truth  of 
the  dictum  (Lucas-Championniere,  1910)  that  "a  certain  amount  of 
motion  between  the  fragments  encourages  the  formation  of  callus," 
I  am  firmly  of  the  opinion  that  even  the  most  careful  immobilization 
by  splints  allows,  and  proper  care  of  the  soft  parts,  as  above  indicated, 
provides  that  "certain  amount"  of  motion  which  is  desirable,  and  that 
any  surgeon  who  attempts  more,  in  the  vain  idea  that  he  is  following 
modern  teaching,  will  succeed  either  in  stirring  up  such  an  amount 
of  callus  (especially  in  children)  as  to  cause  deformity  and  injurious 
pressure  on  the  soft  parts,  or  will  (in  most  adults)  leave  his  patient 
with  an  ununited  fracture.  When  the  ends  of  the  bones  become 
"sticky,"  and  no  tendency  to  displacement  exists,  the  surgeon  may 
then  begin  at  each  dressing  to  make  very  limited  degrees  of  passive 
motion  in  the  neighboring  joints,  meanwhile  maintaining  support 
at  the  seat  of  fracture.  Under  no  circumstances  should  the  passive 
motion  cause  pain.  When  union  is  firm  enough  for  all  external 
support  to  be  discontinued,  function  usually  will  be  more  comfort- 
ably and  quickly  recovered  by  active  movements  by  the  patient 
himself,  than  by  further  attempts  at  passive  motion;  and  if  a  fracture 
has  been  treated  properly  in  the  first  place,  massage  rarely  will  be 
necessary  to  accelerate  the  cure.  The  average  period  of  disability 
following  simple  fractures,  according  to  the  statistics  of  the  Fracture 
Committee  of  the  American  Surgical  Association  (1915)  is  as  follows: 
humerus,  eight  to  twelve  weeks;  radius  and  ulna,  over  ten  weeks; 
femur,  six  and  a  half  months;  tibia  and  fibula,  four  and  a  quarter 
months;  ankle,  four  and  a  quarter  months. 

Operative  Treatment  of  Simple  Fractures. — There  are  only  two 
indications  for  the  "open  method"  of  treating  simple  fractures, 
so  strenuously  advocated  by  Lane  (1905)  and  other  surgeons:  (1) 
If  the  fracture  cannot  be  reduced  properly  without  operation.  (2)  If 
proper  reduction  cannot  be  maintained  without  direct  fixation  of 
the  fragments. 


:;ll  FRACTURES 

I.  When  Proper  Reduction  is  Impossible,  Impossibility  is  here 
;i  relative  term,  since  what  is  impossible  for  one  surgeon  may  not 
be  so  for  another;  and  I  use  the  qualification  "proper"  reduction, 
because  I  do  not  wish  to  imply  that  operation  is  indicated  whenever 
accurate,  exact,  perfect  anatomical  replacement  is  impossible,  but 
only  when  such  degree  of  reduction  as  is  described  at  p.  339,  as 
requisite  for  proper  function,  cannot  be  secured  without  open  opera- 
tion. The  chief  causes  of  irreducibilit  y  are  muscular  spasm  (usually 
this  can  be  overcome  by  general  anesthesia,  weight  extension,  or 
sometimes  by  tenotomy),  interposition  of  muscle,  fascia,  etc.,  between 
the  fragments  (sometimes  this  can  be  overcome  by  manipulation 
under  an  anesthetic),  buttonholing  of  one  fragment  in  the  deep 
fascia,  joint-capsule,  etc.  (this  usually  requires  incision),  complete 
rotation  of  a  detached  fragment  (apophysis,  condyle,  etc.),  and  im- 
paction of  Hie  fragments  (if  desirable,  which  is  not  always  the  case, 
this  usually  may  be  overcome  by  manipulation  with  or  without 
an   anesthetic.) 

'2.  When  Subsequent  Displacement  Cannot  be  Prevented.-  This  also 
is  a  relative  condition,  depending  upon  the  skill  of  the  surgeon  in 
devising  and  applying  efficient  retentive  apparatus,  and  upon  the 
extent  to  which  displacement  occurs.  In  the  aged  or  feeble  it  may 
be  wiser  to  permit  recovery  with  considerable  deformity  than  to 
undertake  an  inexpedient  operation.  Uncontrollable  displacement 
generally  is  due  to  the  nature  of  the  fracture  itself  (marked  obliquity, 
much  comminution,  etc.),  to  muscular  action,  or  to  the  refractor;/ 
conduct  of  the  patient. 

Apart  from  fractures  of  the  patella,  which  are  conceded  to  require 
operation  (because  of  irreducibility)  unless  positive  contraindications 
exist,  the  two  forms  of  injury  in  which  operation  is  most  often  urged, 
are  fractures  of  both  bones  of  the  forearm,  and  those  of  the  femur; 
so  far  as  I  am  aware,  however,  it  has  yet  to  be  shown  that  operative 
methods  in  these  instances  can  be  safely  applied  by  the  average 
surgeon,  or  that  he  can  secure  by  uniform  resort  to  operation  as 
satisfactory  results  in  as  large  scries  of  consecutive  cases  as  he  can 
obtain  by  conservative  treatment. 

If  operation  is  decided  upon,  it  is  best  done  either  on  the  day  of 
injury  or  not  until  about  the  end  of  the  first  week,  or  early  in  the 
second  week  after  the  injury,  since  at  this  time  the  primary  swelling, 
etc.,  will  have  subsided,  and  any  callus  that  may  have  formed  still 
will  be  soft  and  easily  removed;  moreover,  infection  is  less  likely 
to  follow  than  if  early  operation  is  attempted.  The  operation,  which 
should  be  strictly  aseptic,  consists  in  exposing  the  fracture  through  the 
proper  muscular  interspace,  excising  exuberant  callus,  removing 
interposed  soft  tissues,  and  in  securing  reduction  (which  is  not  always 
easy)  if  possible  without  resection  of  bone.  Then  if  very  slight 
tendency  to  dislocation  of  the  fragments  exists  it  is  not  necessary 
to  use  mechanical  means  to  hold  the  ends  in  apposition,  provided 
the   surgeon  feels  capable  of  maintaining  reduction  by   his  external 


OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES         345 

dressings.  It'  there  is  still  ;t  tendency  to  displacement,  the  fragments 
(in  the  case  of  small  hones)  should  be  sutured  with  heavy  chromic 
catgut,  which  will  not  be  absorbed  until  union  is  so  firm  as  to  prevent 
subsequent  displacement;  in  the  shafts  of  the  long  bones  it  is  safer 
to  use  a  metal  plate,  since  maintenance  of  reduction  by  external 
dressings  alone  usually  is  difficult.  My  own  preference  is  for  the 
form  of  plates  used  by  Lambotte  (1907);  these  are  of  steel,  of  various 
sizes,  shaped  to  fit  the  bone  and  are  applied  to  the  bone  beneath  the 


Fig.  327.  —  X-ray  of  re-fracture  of 
humerus  through  old  fibrous  union,  two 
years  and  six  months  after  original  injury. 
See  Fig.  328.  Walter  Reed  General  Hos- 
pital. 


Fig.  32s. — X-ray  of  fracture  of  humerus 
with  Lambotte  plate  in  place  after  resec- 
tion of  the  sclerosed  ends  of  bono  as  a 
mortise  and  tenon  joint.  Perfect  function 
recovered.     Same  case  as  Fijr.  327. 


periosteum  (Figs.  327  and  328).  Three  or  four  screws  are  inserted  in  each 
fragment;  the  holes  are  bored  by  a  suitable  drill  (Fig.  329)  or  dental 
engine,  should  extend  into  the  medulla  and  should  be  slightly  less  in  dia- 
meter than  the  screws;  the  screws  should  have  round  heads,  should  have 
the  thread  carried  up  to  their  heads  and  should  be  just  long  enough  to 
enter  the  medullary  cavity.  The  use  of  plates  has  almost  super- 
seded wire  sutures  since  even  in  smaller  bones  (clavicle,  ulna,  fibula) 
plates  are  efficient  and  may  be  easily  applied.  Occasionally  the 
mandible  requires  direct  fixation,  and  here  a  wire  suture  is  usually 


246 


Fit  ACT  l  ■/.'/•> 


preferable  to  a  plate.  A  plate  should  not  be  applied  in  a  subcutaneous 
situation,  as  it  will  there  be  exposed  to  injury  and  may  require  sub- 
sequenl  removal.  In  the  tibia  the  plate  is  to  be  applied  to  the  fibular 
surface.  II'  wire  is  \\>v<\  phosphor  bronze  wire,  which  is  much  more 
pliable  and  stronger,  is  preferable  to  silver  wire  which  breaks  easily. 
Lambotte  uses  copper  wire.  In  the  ease  of  oblique  fractures,  where 
the  obliquity  exceeds  twice  the  diameter  of  the  bone,  cerclage  is  prefer- 
able to  plating:  The  wire  is  simply  wrapped  around  the  seat  of  fracture, 
tightened  by  twisting,  and  the  ends  hammered  down  against  the  bone. 
Two  wires  should  be  used,  one  at  each  end  of  the  fracture,  for  better 
security.     The  wire  should  be  heavy — 2  mm.   in  diameter  for  the 

femur.  Milne,  Parham  (1913)  and 
others  have  devised  bands  of  flexible 
steel  for  the  same  purpose  which 
have  been  used  with  satisfaction  by 
many  surgeons  (Fig.  330).  Frag- 
ments of  cancellous  bone  are  best 
fixed  bv  Lambotte's  self-boring  screws 
(Figs.  331,  332). 

After  open  operation  the  process 
of  union  sometimes  is  delayed,  and 
in  a  fair  proportion  of  cases  operated 
on  by  the  average  surgeon,  a  mild 
degree  of  infection  occurs  and  only 
fibrous  union  results.  When  the 
operative  treatment  of  simple  frac- 
tures is  confined,  as  it  should  be,  to 
skilful  surgeons  with  all  the  facilities 
afforded  by  the  best  modern  hos- 
pitals, better  results  are  obtained. 

Treatment  of  Complicated  Frac- 
tures.— Rupture  of  the  main  artery 
or  vein  of  a  limb  complicating  a  frac- 
ture of  the  part  requires  the  same 
treatment  as  when  no  fracture  is 
present  (p.  265) ;  if  gangrene  follows, 
amputation  should  be  done  at  the  site  of  rupture;  but  if  the  axillary 
artery  is  ruptured  in  a  case  of  fracture  of  the  upper  part  of  the  humerus, 
it  usually  is  sufficient  to  amputate  through  the  seat  of  fracture ;  and 
if  the  popliteal  artery  is  ruptured,  to  amputate  at  the  knee  if 
the  fracture  is  below  the  knee,  and  through  the  seat  of  fracture  if 
this  is  in  the  femur.  Injuries  of  nerves  require  immediate  suture, 
if  it  is  evident  that  function  is  completely  destroyed;  otherwise  oper- 
ation should  be  delayed  until  after  consolidation  of  the  fracture, 
since  recovery  from  contusion  may  be  nearly  complete.  A  severe 
ivound  of  the  soft  parts  usually  takes  precedence  over  the  fracture, 
and  must  be  treated  suitably  irrespective  of  the  latter;  if  sufficient 
to  render  certain  the  occurrence  of  gangrene,  amputate  at  the  point 


Fig.  329.— Hamilton's  drill. 


TREATMENT  OF  COMPOUND  FRACTURES 


Ul 


of  injury  to  the  soft  parts.  Dislocation  of  the  neighboring  joint, 
most  often  encountered  at  the  shoulder,  usually  requires  incision 
and  direct  replacement  of  the  luxated  fragment;  though  sometimes 
it  is  possible  to  secure  reduction  by  manipulation  after  putting  up 
the  fracture  in  splints;  operation  is  best  postponed  until  seven  or 
eight  days  after  the  injury. 


Fig.  330. — Parham  bands  on  oblique  fracture  of  humerus.  Irreducible  under  ether 
(upper  fragment  entangled  in  biceps).  Operation  ten  days  after  injury.  Was  out  of 
work  only  ten  weeks.     Episcopal  Hospital. 


Treatment  of  Compound  Fractures. — If  the  limb  is  so  severely 
injured  that  gangrene  is  sure  to  occur,  or  if  it  would  prove  useless 
even  if  it  could  be  saved,  it  is  best  to  amputate  at  once;  the  site  of 
section  of  the  bones  in  such  cases  is  determined  by  the  condition 
of  the  soft  parts  available  for  making  flaps. 

A  fracture  which  is  made  compound  merely  by  the  protrusion 
of  the  bones  through  the  soft  parts  is  much  less  dangerous  than 
one  in  which  the  soft  parts  have  been  crushed  or  pulpefied  by  the 
same  force  which  produced  the  fracture;  because  in  the  latter  case 
there  is  much  greater  devitalization  of  tissue,  infection  is  carried 
deeply  into  the  soft  parts,  and  comminution  of  the  bones  is  the  rule. 


348 


fractures 


A  compound  Fracture  in  itself  requiring  amputation,  and  compli- 
cated by  ;i  simple  fracture  higher  in  the  same  limb,  usually  will 
require  amputation  ;it  the  highest   point  of  injury. 


Fig.  331. — Woman,  fifty-six  years  old, 
with  extension-abduction  fracture  at  ankle. 
Failure  of  accurate  reduction  would  have 
entailed  persistent  disability. 


Fig.  332. — Absolute  anatomical  reposi- 
tion secured  by  open  operation,  and  main- 
tained by  screw  fixation.  Episcopal  Hos- 
pital. 


A  compound  fracture  involving  a  joint  sometimes  requires  ampu- 
tation (almost  always  at  the  knee),  but  conservative  treatment 
with  strict  antiseptic  methods  often  will  secure  a  useful  limb  even 
if  motion  is  limited. 


Fig.  333. — Compound  fracture  of  humerus,  bone  protruding.     Photographed 
just  before  operation.     (See  Fig.  334.)     Episcopal  Hospital. 

If  it  appears  in  any  way  likely  that  a  useful  limb  can  be  saved, 
especially  in  the  upper  extremity,  the  surgeon  must  undertake  repair 
of  the  soft  parts  and  reduction  of  the  fragments  with  antiseptic 
methods  as  detailed  at  p.  1 07 .     In  almost  every  ease  the  patient  should 


TREATMENT  OF  COMPOUND  FRACTURES 


549 


be  anesthetized,  and  the  primary  dressing  made  to  assume  the  character 
of  a  formal  operation.  If  the  ends  of  the  bones  project  through 
the   soft  parts,  they   should   not   be   reduced  until   alter   the  entire 


Fig   334  —Silver  plate  on  compound  fracture  of  humerus.    (See  Figs.  333  and  335.) 

Episcopal  Hospital. 

wounded  area  has  been  surgically  cleansed.  The  wound  in  the  soft 
parts  frequently  has  to  be  enlarged,  to  permit  of  reduction  and  repair 
of  the  deeper  tissues  (Fig.  333).    It  seldom  is  necessary  to  resect  the 


350 


FRACTURES 


ends  of  the  bones,  reduction  usually  being  possible  by  relaxing  the 
muscles  by  the  position  of  the  limb,  and  bending  the  bones  at  an 
angle  until  their  ends  meet,  then  using  the  apposed  fragments  as  a 
fulcrum  on  which  to  straighten  the  limb  out  again. 

Where  the  bones  are  much  comminuted,  such  fragments  as  are 
entirely  detached  should  be  removed,  while  those  that  are  partly  adher- 
ent should  be  replaced,  in  the  hope  that  they  will  aid  in  procuring 
union.  Often  the  soft  parts  are  stripped  SO  widely  from  the  bones  that 
it  is  impossible  to  prevent  recurrence  of  displacement  even  when  reduc- 
tion is  easy.  Under  these  circumstances  the  bones  maybe  fixed  by 
some  form  of  internal  splint  (Fig.  334);  usually  it  is  better  not  to  plate 
a  recent  compound  fracture  (since  bony  union  seldom  follows  such  a 
course),  but  to  postpone  the  plating  until  the  soft  parts  have  healed  and 
asepsis  can  be  assured.  Particular  attention  should  be  paid  to  suture 
of  nerves,  muscles,  and  tendons.  The  wound,  unless  very  slight, 
should  be  drained  for  about  forty-eight  hours;  by  arranging  the 
dressings  as  described  at  p.  1G0,  the  drainage  tube  may  be  removed 


Fig.  335. — Fibrous  union  following  plated  compound  fracture  of  left  humerus. 
(See  Figs.  333  and  334.)     Episcopal  Hospital. 

without  disturbing  the  fracture.  In  the  lower  extremity,  a  gypsum 
splint,  trapped  over  the  seat  of  injury,  makes  a  very  good  appliance 
for  the  treatment  of  compound  fractures;  but  in  the  upper  extremity 
ordinary  splints  used  in  cases  of  simple  fracture  are  quite  satisfactory. 
It  is  very  seldom  in  civil  life  that  injury  to  the  soft  parts  is  seen  corn- 
comparable  to  wounds  encountered  habitually  in  the  German  War. 
For  such  cases  the  splints  described  in  Chapter  VII  (p.  204)  are  well 
adapted.  Frequently  irrigation  (p.  168)  must  be  employed  for  several 
days  to  ensure  vitality  of  the  limb;  and  the  frequency  of  dressings 
must  be  determined  by  the  condition  of  the  soft  parts.  Union  is  much 
more  delayed  than  in  simple  fractures;  and  though  fibrous  union 
often  is  the  best  that  can  be  secured,  it  may  furnish  the  patient  with 
a  useful  limb  (Fig.  335). 

Treatment  of  Badly  United  Fractures. — If  the  case  is  seen  before 
firm  union  has  occurred,  the  position  usually  may  be  improved  by 
judicious  application  of  pads  under  the  splints,  or  even  by  refractur- 
ing  the  bones  manually  and  dressing  them  in  the  improved  position. 


TREATMENT  OF  M ALU N ION 


351 


The  question  whether  impacted  fractures  should  be  reduced  is 
discussed  under  the  lesions  of  the  various  bones.  If  the  case 
is  seen  first  after  bony  union 
has  occurred,  it  is  not  always 
advisable  to  attempt  reduction 
of  the  deformity  if  function  is 
good,  since  non-union  may  result, 
or,  even  if  firm  union  is  secured, 
loss  of  function  may  accompany 
it.  Shortening,  as  such,  unless 
due  to  angular  deformity,  scarcely 
ever  can  be  remedied;  indeed, 
to  secure  end-to-end  apposition 
of  the  fragments  it  often  is 
necessary  to  resect  their  ends, 
thus  increasing  shortening;  and 
attempts  to  lengthen  a  bone  by 
oblique  division  usually  are  nulli- 
fied by  contractures  in  the  sur- 
rounding soft  parts.  On  these 
accounts,  operative  measures 
are  directed  toward  overcoming 
lateral  displacement,  rotatory  and 
angular  deformity,  or  to  the  re- 
moval of  exuberant  callus. 

Careful  skiagraphic  studies 
should  be  made  of  the  fractured 
region,  so  that  the  surgeon  may 
plan  his  method  of  operation 
in  advance.  In  some  cases 
simple  refrachire,  by  the  hands 
or  osteoclast  (p.  458),  will  be 
sufficient;  in  others  (Fig.  336)  it 
is  necessary  to  cut  down  on  the  fragments  and  resect,  treating  the  case 
then  as  one  of  recent  fracture  or  as  an  ununited  fracture  (p.  353); 


Fig.  336. — Vicious  union  following  frac- 
ture of  forearm;  angular  deformity  and  loss 
of  rotation.  Suitable  for  operation.  Epis- 
copal Hospital. 


Fig.  337. — Deformity  from  separation  of  lower  radial  epiphysis.     Reduction  by 
linear  osteotomy.     Episcopal  Hospital. 

while  in  still  others,  linear  or  cuneiform  osteotomy  (p.  458)  will  give 
the  best  results  (Fig.  337). 


F/iAC'l  I  ■/.'/■>• 


Ununited  Fractures.  The  distinction  between  delayed  union  and 
ununited  fracture,  as  was  pointed  out  at  p.  339,  is  difficult  to  draw; 
save  that  in  the  former  condition  union  frequently  occurs  under 
conservative  treatment,  while  in  ununited  fracture  it  rarely  does. 
The  most  marked  degree  of  non-union,  constituting  pseudarthrosis, 
is  that  in  which  a  bursa  tonus  between  the  ends  of  the  fragments, 
there  being  almost  a  Bail-like  joint  present  (Fig.  338).  In  ordinary 
cases  there  is  rather  dense  fibrous  tissue  between  the  ends  of  the 
bones,  which  are  pointed  and  atrophic;  and  while  this  may  prevent 

lateral    displacement  of  the    fragments,  it' 
allows  angulation  at  the  seat  of  fracture. 

Causes. — The  chief  causes  of  non-union  in 
fractures  are :  (1)  Failure  to  secure  end-to- 
end  apposition  of  fragments.  (2)  Com- 
minution of  the  fragments  especially  in 
compound  fractures  where  there  may  be 
marked  loss  of  substance.  (3)  Interposition 
of  soft  tissues.  (4)  Imperfect  immobilization 
soon  after  the  accident.  (5)  Constitutional 
condition  of  the  patient,  rendering  his  pro- 
cesses of  repair  ineffectual.  These  factors, 
several  of  which  may  co-exist,  are  men- 
tioned  in   what    I    believe    is  their  order  of 


Fig.  33S.  —  Pseudai- 
throsis  of  humerus  with 
ankylosis  of  elbow,  follow- 
ing compound  comminu- 
ted fracture.  Episcopal 
Hospital. 


Fig.  339. — Moulded  binder's-board  splint,  for  delayed 
union  after  fracture  of  both  bones  of  forearm.  Epis- 
copal Hospital. 


frequency,  with  the  possible  exception  of  the  patient's  constitutional 
condition,  which  in  many  cases  undoubtedly  is  the  chief  cause  of 
non-union.  But  it  should  be  noted  that  interposition  of  soft  tissues, 
though  comparatively  infrequent,  always  results  in  non-union  when 
present . 

Diagnosis. — The  diagnosis  rarely  presents  difficulties,  if  the  seat  of 
injury  is  carefully  and  repeatedly  examined;  it  is  a  truism  to  state 
that  the  firmer  the  union  the  more  difficult  it  is  to  detect  motion. 
A  skiagraph  may  aid,  since  it  will  show  absence  of  bony  structure 
between  the  fragments. 


TREATMENT  OF  NONUNION 


353 


J  -.  -^» — .~- 


Treatment. — The  treatment  depends  upon  whether  the  patient  is 
seen  during  the  stage  of  delayed  union,  or  whether  he  first  comes 
under  the  surgeon's  observation  when  non-union  has  existed  for 
months  or  years.  The  surgeon  should  endeavor  to  ascertain  the  cause 
of  the  condition,  and  should  attend  to  the  patient's  general  health, 
administering  cod  liver  oil,  phosphates,  thyroid  extract,  etc.  If 
separation  of  fragments  can  be  excluded,  conservative  measures  should 
be  tried  first.  In  the  case  of  delayed  union,  the  first  thing  to  do 
is  to  try  what  strict  immobilization  for  a  period  of  four  to  six  weeks 
will  accomplish:  this  frequently  secures  firm  union;  but  if  it  fails,  trial 
should  be  made  of  functional  use  of  the  part,  with  the  fracture 
supported  in  splints,  braces,  etc.;  and  of  rather  vigorous  massage  of 
the  affected  limb.  A  fracture  of  the  leg 
bones  with  delayed  union  frequently  will 
grow  firm  when  the  patient  begins  to 
walk  around  in  his  gypsum  case;  for 
delayed  union  of  the  femur  a  well  fitting 
walking  brace  is  more  efficient;  while 
for  the  humerus  or  forearm  a  light  splint 
of  binder's-board  to  support  the  seat  of 
fracture  will  allow  free  use  of  the  hand 
and  elbow.  The  patient  (Fig.  339),  a 
skiagraph  of  whose  forearm  is  shown  in 
Fig.  402,  cured  his  own  delayed  union 
by  returning  to  his  black-smithing  work, 
securing  perfect  functional  use  in  spite 
of  the  bony  deformity,  which,  however, 
was  not  appreciable  through  the  thick 
mass  of  muscles. 

Should  this  degree  of  stimulation  fail 
to  develop  osseous  union,  the  patient 
may  be  anesthetized,  and  the  ends  of  the 
bones  vigorously  rubbed  together,  and 
then  immobilized  for  a  few  weeks;  this 
procedure  often  arouses  osteogenetic 
processes  and  secures  firm  union  when  milder  methods  are  ineffectual. 
Bier  (1905)  advocated  stimulation  of  osteogenesis  by  injecting  around 
the  ends  of  the  fragments  30  to  40  c.c.  of  venous  blood  freshly  drawn 
from  the  patient. 

If  conservative  measures  fail,  the  question  of  operation  rises; 
but  in  every  case  the  surgeon  should  stop  to  consider  whether  any 
operation  is  apt  to  improve  matters,  or  whether  the  patient  has  not 
a  sufficiently  useful  limb  as  it  is.  The  mere  doing  of  an  operation 
does  not  ensure  the  occurrence  of  bony  union;  it  may  leave  the 
patient  with  non-union,  and  with  increased  shortening,  since  resec- 
tion of  the  fragments  may  be  necessary.  But  where  deformity  can  be 
decreased,  and  disability  lessened,  operation  is  indicated. 


Fig.  340. — A  form  of  mortise 
and  tenon  joint  useful  in  opera- 
tions for  ununited  fracture.  (See 
Fig.  328.) 


23 


354 


FRACTURES 


Operation. — The  fracture  being  exposed  through  the  proper  muscular 
interspace,  it  is  found  cither  in  good  alignment  or  not.  (1)  In  the 
former  case  no  reduction  is  required  and  the  best  treatment  consists  in 


Fig.  341. — Sliding  bone  inlay  after  Buchanan's  method. 


Fig.  342. — Non-union  of  radius  and 
ulna,  sixteen  months  after  compound 
fracture.  See  Fig.  343.  Episcopal 
Hospital. 


Fig.  343. — One  year  after  bone  trans- 
plant for  non-union  of  radius.  Five  weeks 
after  same  (sliding)  for  non-union  of  ulna. 
See  Figs.  341  and  342.  Episcopal  Hospital. 


implanting  a  bone  transplant  (p.  248) :  with  circular  saw  a  gutter  is 
cut  in  the  fragments  for  7  to  10  cm.  each  side  of  the  fracture,  and  the 
transplant  wedged  into  place;  this  opens  up  healthy  bone  above  and 


TREATMENT  OF  NONUNION 


355 


below  the  sclerosed  ends,  and  the  bone  transplant  which  acts  as  an  osteo- 
conductive  bridge  is  sufficiently  strong,  in  combination  with  external 
dressings  and  splints,  to  secure  immobilization  of  the  fracture  (Figs. 
342,  343).  In  cases  of  loss  of  bone  substance,  also,  a  free  transplant  of 
bone  is  used  to  bridge  the  gap.  (2)  If,  on  the  other  hand,  the  fragments 
are  not  in  good  apposition,  it  is  necessary  first  to  secure  reduction: 
exuberant  callus  is  removed  with  gouge,  chisel,  and  Volkmann's  sharp 
spoon,  and  the  ends  of  the  fragments  are  freshened  with  the  saw,  the 
least  possible  amount  of  bone  being  removed  which  exposes  heal  hy 


Fig.  344. — Ununited  fracture  of  the  neck  of  the  femur  treated  hy  bone  transplan- 
tation.    Bony  union;  free  motion.     Episcopal  Hospital. 

osseous  structure  and  allows  proper  apposition.  In  some  cases  simple 
end-to-end  approximation  is  sufficient;  in  others  a  form  of  mortise 
and  tenon  joint  is  preferable  (Fig.  340).  In  either  case  it  is  desir- 
able to  fix  the  fragments,  and  while  the  use  of  a  bone  transplant  is 
preferable  in  most  cases,  there  may  be  such  tendency  to  displace- 
ment of  the  fragments  that  fixation  by  plating  or  cerclage  may  be 
required;  either  alone,  or  in  addition  to  the  insertion  of  a  bone 
transplant. 

The  wound  should  not  be  drained,  if  strict  hemostasis  has  been 


356  FRACTURES 

secured  before  closing  it,  hut  in  doubtful  cases  it  is  safer  to 
leave  a  tube  in  place  for  thirty-six  to  forty-eight  hours.  If  a  sinus 
persists  after  recovery,  as  sometimes  is  the  case  when  the  plate 
or  wire  suture  has  been  used,  the  foreign  body  should  be  removed, 
otherwise  it  may  be  allowed  to  remain  indefinitely.  ]  )r.  Edward 
Martin  removed  a  silver  plate  inserted  by  my  father,  which  only  at 
the  expiration  of  seventeen  years  began  to  work  loose  and  produced 
a  sinus. 

SPECIAL  FRACTURES. 

The  general  subject  of  fractures  and  their  treatment  has  been 
so  fully  discussed  in  the  preceding  pages,  and  so  many  excellent 
monographs  on  the  subject  are  readily  obtainable,  that  in  speaking 
of  the  injuries  of  the  several  bones  I  shall  be  as  brief  as  possible. 
As  fractures  of  the  skull  and  of  the  spine  are  of  interest  chiefly  in 
connection  with  injuries  to  their  contained  structures,  their  con- 
sideration is  postponed  to  Chapter  XVI  and  XYII  respectively. 

FRACTURES  OF  THE  FACE  BONES. 

Injuries  of  the  face  bones  are  due  almost  without  exception  to 
direct  violence;  edema  and  ecchymosis  often  are  marked,  owing 
to  the  abundance  of  loose  cellular  tissue  overlying  the  bones,  and 
hemorrhage  into  the  nasal  or  oral  cavities  is  quite  frequent,  the 
fractures  being  compound  on  the  mucous  surface.  Antiseptic  sprays, 
mouth  washes,  etc.,  are  indicated  under  such  circumstances.  Union 
occurs  rapidly. 

Nasal  Bones. — These  may  be  crushed  directly  inward,  or  as  is 
more  often  the  case,  may  suffer  lateral  deviation.  The  epistaxis  fol- 
lowing the  injury  usually  subsides  in  a  few  minutes.  The  deformity  is 
characteristic,  and  the  diagnosis  usually  is  made  by  inspection  (Fig. 
345),  and  is  confirmed  by  crepitus  as  the  displacement  is  corrected. 
This  often  may  be  accomplished  by  external  pressure,  but  in  some 
cases  is  more  effectually  secured  by  leverage  from  within  by  a  bone 
elevator.  There  is  no  marked  tendency  for  recurrence  of  deformity, 
and  retentive  appliances  generally  are  useless  save  to  protect  the 
part  from  injury.  A  strip  of  adhesive  plaster  may  be  carried 
across  both  cheeks  and  the  bridge  of  the  nose,  as  a  precaution.  As 
swelling  subsides,  deformity  may  appear  more  evident,  and  often  it 
is  desirable  to  mould  the  nose  into  shape  by  pressure  every  day  or  so 
during  the  first  week.  Rarely  can  complete  symmetry  be  restored. 
Union  is  firm  in  ten  days  or  two  weeks. 

Malar  Bone. — This  is  rarely  fractured.  Usually  there  is  depression, 
(Fig.  346)  which  is  best  overcome  by  early  incision  under  an  anesthetic 
and  direct  elevation  of  the  fragment.  Fractures  of  the  zygoma  often 
are  comminuted,  and  require  the  same  treatment. 

Maxilla. — Fractures  of  this  bone  are  not  frequent,  but  sometimes 
occur  with  multiple  fractures  of  the  face.    They  are  often  compound 


FRACTURES  OF  THE  FACE  BONES 


357 


into  the  nose  or  mouth.  Asymmetry  of  the  alveolar  process  is  the 
main  diagnostic  point.  Impaction  is  usual,  and  must  be  reduced 
to  restore  symmetry.  If  maintenance  of  reduction  proves  difficult,  it 
is  well  to  have  a  special  splint  constructed  bv  a  competent  dentist 
(Aller,  1914). 


Fig.  345. — Fracture  of  nose,  eighteen  hours 
after  injury.     Episcopal  Hospital. 


Fig.  346. — Fracture  of  right  malar 
bone,  from  pressure  by  elbow  in  playing 
basket  ball.     Episcopal  Hospital. 


Mandible. — Fracture  of  the  lower  jaw  is  the  most  important,  and, 
with  exception  of  the  nasal  bones,  probably  the  most  frequent  of 
those  of  the  face.  It  is  due  frequently  to  a  blow  from  the  fist,  some- 
times to  the  kick  of  a  horse,  to  sudden  jerking  upward  of  a  mule's 
head,  or  to  a  fall.  Fracture  involves  the  ramus,  the  body  of  the  bone, 
the  condyle,  or  the  coronoid  process. 

Fracture  of  the  body  of  the  mandible  occurs  either  near  the  symphysis, 
or,  most  often,  anterior  to  the  insertion  of  the  masseter  muscle.  A 
rare  fracture  is  detachment  of  the  mental  eminence,  carrying  the 
genial  tubercles,  and  (by  relaxation  of  the  geniohyoid  and  geniohyo- 
glossus  muscles)  permitting  the  tongue  to  fall  backward,  perhaps 
suffocating  the  patient;  this  fracture  requires  immediate  operation 
with  suture  of  the  fragment  (G.  G.  Davis,  1894).  A  similar  condition 
may  exist  in  a  double  fracture  of  the  jaw,  on  each  side  of  the  symphysis. 
Fracture  in  front  of  the  masseter  muscle,  or  posterior  to  the  mental 
foramen,  is  the  most  frequent  injury:  the  line  of  fracture  usually 
is  bevelled,  permitting  separation  of  the  fragments  as  the  posterior 
is  drawn  toward  the  middle  line  by  the  mylohyoid  and  internal 
pterygoid  muscles;  the  corresponding  muscles  of  the  uninjured  side 
increase  the  deformity  by  acting  similarly  on  the  unbroken  side  of 
the  jaw  (Fig.  347).  In  most  cases  good  results  follow  immobilization 
for  three  or  four  weeks  by  a  modified  Barton  bandage  using  the 


358 


Fh'.\<  I  l  Kk'S 


upper  jaw  as  a  splint;  tendency  to  displacement  becomes  less  a  lew 
days  alter  the  injury.  Fixation  by  a  special  interdental  splint  of 
gutta-percha,  such  as  is  made  by  dentists,  though  it  may  be  un- 
necessary, undoubtedly  promotes  the  patient's  comfort,  and  recovery 
ensues  with  little  or  no  deformity.  Double  or  compound  fractures, 
or  fractures  of  the  ramus  to  which  no  dental  prosthesis  can  be  applied, 
frequently  require  operation,  with  wiring  of  the  fragments. 


Fig.  347. 


-Skiagrai 


i  of  fracture  of  mandible  in  front  of  angle, 
seven  years.     Episcopal  Hospital. 


Age  twenty- 


Fracture  through  the  neck  of  the  condyle  is  a  serious  injury,  often 
leading  to  ankylosis  (p.  709) :  the  external  ptyergoid  muscle,  attached 
to  the  condyle,  rotates  its  broken  surface  forward,  and  as  it  is  very 
difficult  to  replace  this  by  manipulation,  operation  is  indicated.  If 
the  fracture  is  overlooked  in  children,  disuse  of  the  jaw  following 
ankylosis  may  result  in  marked  retrognathism. 

Fracture  of  the  coronoid  process,  a  very  rare  accident,  is  difficult 
to  detect,  as  separation  of  the  fragment  is  prevented  by  attachment 
of  the  temporal  muscle  far  down  the  inner  side  of  the  ramus.  Treat- 
ment consists  in  procuring  rest  by  bandages  until  acute  symptoms 
subside. 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK. 

Sternum. — This  is  an  unusual  fracture,   generally  due  to  direct 
violence,  the  patient  being  crushed  beneath  a  fall  of  earth,  etc.; 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK 


359 


some  cases  are  due  to  muscular  action,  such  as  violent  lifting  effort, 
parturition,  etc.  Visceral  injury  is  to  be  feared,  especially  in  cases 
caused  by  direct  violence;  it  is  manifested  by  hemoptysis,  dyspnea, 
cyanosis,  subcutaneous  emphysema,  etc.  The  line  of  fracture  usually 
is  transverse,  and  sometimes  consists  in  a  diastasis  between  the 
manubrium  and  gladiolus;  more  often  a  true  fracture  exists  above 
or  below  this  joint,  the  lower  fragment  projecting  in  front  of  the 
upper.  Attempts,  not  always  successful,  are  made  to  reduce  the 
deformity  by  hyperextension  of  the  spine  over  a  small  pillow,  and 
drawing  the  arms  backward.  Crepitus  may  be  detected  during  this 
manoeuvre.  The  sternal  region  is  then  immobilized  by  broad  strips 
of  adhesive  plaster,  passed  from  axilla  to  axilla,  while  the  chest  is 
collapsed  in  expiration.  In  uncomplicated  cases  recovery  is  rapid, 
union  being  firm  in  three  or  four  weeks.  Suppuration  may  follow 
in  case  of  extravasation  into  the  anterior  mediastinum,  and  is  to 
be  treated  by  intercostal  incision  or  trephining  the  sternum. 

Fracture  of  the  ensiform  process  may  unite  with  deformity,  the 
xiphoid  being  turned  backward  and  causing  gastric  distress  (xipho- 
dynia).    This  is  best  relieved  by  excision  of  the  xiphoid. 

Ribs.  —  Fractures  of  the  ribs  dispute 
with  those  of  the  clavicle  the  first  place 
in  frequency  among  all  fractures.  The 
injury,  commonest  in  male  adults,  may 
be  caused  by  direct  or  indirect  violence; 
in  the  latter  case  the  force  usually  is 
applied  antero-posteriorly,  and  the  ribs 
break  at  their  weakest  point  when  the 
limit  of  elasticity  has  been  reached.  The 
ribs  most  often  broken  (usually  two  or 
more  [at  once)  are  those  from  the  fifth 
to  the  ninth,  usually  in  the  axillary  or 
posterior  axillary  line.  There  is  great 
pain  on  forced  inspiration,  and  on  sudden 
motion;  localized  tenderness,  sometimes 
distinct  mobility  and  crepitus.  By  using 
a  stethoscope  crepitus  can  be  detected  in 
almost  all  cases,  and  may  be  traced  up 
to  its  origin  even  from  a  distance.  Vis- 
ceral complications  are  unusual  but 
serious;  they  should  be  looked  for:  subcu- 
taneous emphysema  indicates  partial  rup- 
ture of  the  lung;  hemothorax  is  a  grave 
complication,  and  traumatic  pneumonia 
very  fatal. 

Treatment. — Treatment  comprises  immobilization,  but  rarely  con- 
finement to  bed.  Broad  strips  of  adhesive  plaster  are  applied,  at 
the  end  of  each  forced  expiration  and  with  the  arm  on  the  affected 
side  dependent ;  they  run  from  below  upward,  beginning  at  the  spine, 


Fig.  348. — Adhesive  plaster- 
strapping  for  fracture  of  ribs, 
applied  with  arm  dependent;  arm 
raised  before  photograph  was 
taken.     Episcopal  Hospital. 


360 


FRACTURES 


and  extending  just  to  beyond  the  midline  in  front  (Fig.  348).  Im- 
mobilization of  both  sides  of  the  chest  is  undesirable.  This  st nip- 
ping should  be  renewed  as  often  as  it  comes  loose,  every  five  or  six 
days;  and  should  be  continued  for  four  or  five  weeks.  For  the 
persistent  pain  and  neuralgia  which  sometimes  follow  these  injuries, 
massage  and  antirheumatic  remedies  may  be  tried;  the  disability 
seldom  persists  long,  but  may  eventually  demand  excision  of  callus 
for  its  relief.  In  one  such  patient  sent  to  me  with  the  diagnosis  of 
cholelithiasis,  the  rib  was  found  ununited  one  year  after  injury;  symp- 
toms were  relieved  by  excising  the  affected  portion. 

Costal  Cartilages.—  These  sometimes  become  detached  at  their 
junction  with  the  ribs.  Treatment  is  similar  to  that  for  fracture  of 
the  ribs. 


Fig.  349. — Fracture  of  pelvis,  from  antero-posterior  force.  Note  diastasis  of  sym- 
physis; fracture  through  innominate  bone  from  iliac  crest  to  sacrosciatic  notch; 
separation  of  sacro-iliac  joint.    Recovery.    Episcopal  Hospital. 

Pelvic  Bones.  —  These  fractures  usually  are  caused  by  direct 
violence,  and  are  of  interest  chiefly  from  their  visceral  complica- 
tions, which  are  met  with  in  about  one-sixth  of  the  cases  (Ash- 
hurst,  1909),  the  general  mortality  being  over  30  per  cent.  The 
most  important  are  those  fractures  which  break  the  ring  of  the  pelvis: 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK  361 

when  the  force  is  received  antero-posteriorly,  as  when  a  heavy  weight 
knocks  a  man  down  and  lands  on  his  symphysis  pubis,  the  anterior  part 
of  the  pelvis  is  crushed  inward,  fracturing  the  rami  of  the  pubes  and 
ischium  on  one  or  both  sides  or  bursting  the  symphysis  pubis,  and 
spreading  the  halves  of  the  pelvis  apart,  perhaps  causing  diastasis  of  the 
sacro-iliac  joints,  or  fracture  of  the  ilium  through  the  sacro-sciatic  notch 
(Fig.  349).  When  the  force  is  received  laterally,  the  most  frequent  frac- 
ture which  involves  the  ring  of  the  pelvis  is  a  vertical  fracture  in  the 
neighborhood  of  the  symphysis  pubis,  and  one  of  the  ilium  behind 
the  acetabulum;  but  force  transmitted  through  the  femur  may  cause 
comminuted  fracture  of  the  acetabular  region,  not  involving  the  pelvic 
ring.  Of  fractures  which  do  not  involve  the  pelvic  ring  those 
detaching  one  of  the  iliac  crests  are  most  frequent,  usually  being  due 
to  lateral  force  (Fig.  278),  though  the  anterior  superior  spine  alone  has 
been  detached  by  muscular  action.  The  various  fractures  are  not 
difficult  to  diagnose,  as  displacement  usually  is  quite  appreciable  to 
palpation,  which  should  always  include  rectal  or  vaginal  examination. 
If  displacement  is  slight,  persistent  localized  tenderness,  especially  of 
one  of  the  pubic  rami,  is  a  valuable  sign;  and  a  skiagraph  may  aid. 
Crepitus  often  is  evident  on  attempts  at  motion;  pain  is  experienced 
when  the  trochanteric  regions  are  crowded  together,  or  when  attempts 
are  made  to  move  one  innominate  bone  on  the  other.  While  operation 
may  be  required  for  visceral  complications  (rupture  of  urethra, 
bladder,  abdominal  wall,  internal  hemorrhage,  etc.),  the  fractures 
themselves  generally  unite  with  little  difficulty.  The  pelvis  should 
be  immobilized  by  a  broad  canvas  belt  or  strips  of  adhesive  plaster; 
and  it  often  is  well  to  secure  relaxation  of  the  adductors,  sartorius 
and  rectus  muscles  by  keeping  the  thighs  moderately  flexed.  Some 
disability  may  persist  from  shortening  of  one  lower  extremity,  due 
to  imperfect  replacement  of  the  fragments,  or  from  mobility  due  to 
diastasis  of  one  of  the  pelvic  joints. 

Fracture  of  the  Acetabular  Rim  is  a  rare  injury  due  to  force  trans- 
mitted through  the  femur,  which  may  become  subluxated  upward 
and  backward.  The  diagnosis  is  difficult  without  a  skiagraph.  Treat- 
ment consists  in  applying  wreight  extension  to  the  femur  in  the 
abducted  position,  after  replacing  the  head  in  its  socket,  and  main- 
taining this  position  for  three  or  four  weeks.  Use  of  the  limb  should 
not  be  allowed  for  ten  or  twelve  weeks  after  injury. 

Under  the  name  Central  Dislocation  of  the  Hip  is  described  a  stellate 
fracture  of  the  acetabulum  caused  by  the  head  of  the  femur  being 
driven  through  it  into  the  pelvis  by  direct  violence  acting  in  the 
axis  of  the  femoral  neck;  pregnancy  seems  to  be  a  predisposing  cause. 
Henschen  (1909)  collected  139  cases.  Skillern  (1911)  classifies  the 
lesions  as  "fractura  perforans"  (Fig.  349)  and  "perforata,"  according 
to  the  degree  of  intrapelvic  displacement.  The  diagnosis  is  made 
from  flattening  of  the  trochanter  and  relaxation  of  the  supratrochan- 
teric  structures;  by  palpating  the  luxated  head  in  the  pelvis  by  a 
finger  in  the  vagina  or  rectum;  and  by  recurrence  of  deformity,  with 
crepitus,  after  reduction.    The  intrapelvic  spicules  of  bone  should  not 


.;i,j 


/■•/.'.I (  r /■/,•/•>■ 


l>c  replaced  until  the  head  of  the  femur  has  Keen  withdrawn.  The 
thigh  should  be  dressed  in  plaster  of  Paris  in  a  flexed  and  adducted 
position,  and  the  patient  should  bear  no  weight  on  the  limb  for  two 
or  three  months. 

Fractures  of  the  Sacrum  and  Ischium  are  rare.     The  tuber  isch.il  has 
been  detached  1>y  niuseillar  violence. 


Fig.  350.— Centra 


dislocation  of  right  hip  from  fall  from  aeroplane.  Fractura  perforans. 
Walter  Reed  General  Hospital. 


Fractures  of  the  Coccyx  follow  falls  or  kicks  or  parturition,  and 
may  readily  be  diagnosed  by  inserting  the  index  finger  into  the 
rectum  and  grasping  the  coccyx  between  this  and  the  thumb,  when 
abnormal  mobility  and  perhaps  crepitus  will  be  detected.  If  forward 
displacement  is  persistent,  it  is  best  to  excise  the  coccyx  at  once, 
since  if  the  bone  unites  in  bad  position,  or  if  non-union  results,  there 
often  ensues  in  women  a  train  of  neurasthenic  symptoms  constituting 
the  affection  known  as  coccygodynia.  This  is  characterized  by  local 
pain,  interference  wTith  defecation,  vesical  irritability,  and  sometimes 
a  life  of  invalidism;  all  of  wmich  may  be  cured  by  removal  of  the 
entire  coccyx  at  the  sacrococcygeal  articulation. 


FRACTURES  OF  THE  UPPER  EXTREMITY 


363 


FRACTURES  OF  THE  UPPER  EXTREMITY. 

Clavicle. — The  entire  upper  extremity  depends  on  the  clavicle 
for  its  bony  connection  with  the  trunk,  and  this  bone,  therefore,  is 
exposed  to  all  manner  of  strains 
transmitted  from  the  periphery. 
The  patient  falls  on  the  hand,  or 
on  the  point  of  the  shoulder,  or 
rarely  receives  a  blow  directly  on 
the  clavicle,  which  gives  way  usually 
at  its  weakest  part,  between  the  at- 
tachments of  the  sternomastoid  and 
trapezius  on  its  upper  surface,  and 
those  of  the  pectoralis  major  and 
deltoid  on  its  lower  surface,  ap- 
proximately at  its  middle,  where 
the  two  curves  of  the  bone  meet. 
The  line  of  fracture  nearly  in- 
variably is  oblique  from  before 
backward  and  from  without  inward ; 
and  as  the  main  function  of  the 
bone  is  to  prop  the  shoulder  away 
from  the  trunk,  giving  the  humerus  a  greater  range  of  motion,  the 
main  deformity  consists  in  the  shoulder  falling  inward  and  forward, 


Fig.  351. — Deformity  following  frac- 
ture of  left  clavicle,  much  more  notice- 
able than  the  average  case.  Episcopal 
Hospital. 


Fig.  352. — Skiagraph  of  fracture  of  clavicle,  with  slight  comminution,  from 
direct  violence.    Age  twenty-three  years.     Episcopal  Hospital. 

toward  the  trunk,  by  contraction  of  the  muscles  of  the  axillary  folds, 
while  the  weight  of  the  upper  extremity  causes  slight  dropping  of 


:;iil  FRACTURES 

the  shoulder.  The  inner  end  of  the  clavicle  remains  in  its  normal 
position,  or  possibly  is  raised  a  little  by  the  sternomastoid ;  and  at 
the  outer  end  of  this  fragment  a  depression  can  be  felt,  owing  to  the 
displacement  inward  and  backward  of  the  outer  fragment  (Figs.  351 
and  352).  In  rare  eases  this  presses  on  the  subclavian  vessels  or  the 
brachial  plexus,  but  in  the  vasl  majority  of  cases  the  fracture  is  entirely 
uncomplicated.  Owing  to  the  inward  rotation  of  the  shoulder,  the 
vertebral  border  of  the  scapula  may  become  prominent.  The  diagnosis 
sometimes  is  difficult  in  cases  of  green-stick  fracture,  and  in  fat,  chubby 
children,  in  whom  the  outlines  of  the  bones  may  be  hard  to  detect; 
but  even  in  cases  where  deformity  is  absent,  there  will  be  persistent 
localized  tenderness  at  the  seat  of  fracture.  In  cases  with  deformity, 
the  diagnosis  is  easy,  even  the  attitude  of  the  patient  being  more  or 
less  characteristic;  he  carries  his  head  bent  toward  the  affected  side, 
supports  the  injured  limb  with  his  other  hand,  and  is  unwilling  or 
unable  to  raise  the  arm  from  the  side. 

Fracture  of  the  Outer  End  of  the  Clavicle,  a  much  rarer  injury, 
generally  is  due  to  direct  violence;  if  the  fracture  occurs  through  the 
coraco-clavicular  ligaments  there  is  little  displacement,  but  if  external 
to  them,  the  outer  fragment  is  carried  downward  and  inward,  a 
displacement  which,  owing  to  the  posterior  convexity  of  the  curve 
at  this  point,  causes  the  inner  fragment  to  protrude  posteriorly,  and 
produces  a  characteristic  deformity. 

Treatment  of  Fractured  Clavicle. — Reduction  of  the  deformity  is 
difficult,  and  accurate  retention  of  the  fragments  nearly  impossible; 
nevertheless,  such  good  functional  results  follow7  conservative  treat- 
ment that  operation  is  very  rarely  performed,  especially  as  a  scar 
would  be  more  conspicuous  than  the  moderate  amount  of  deformity 
which  usually  follows  conservative  treatment.  By  placing  the  patient 
flat  on  the  back,  on  a  hard  bed,  and  with  a  folded  sheet  or  firm,  flat 
pillow  across  the  bodies  of  the  scapulae,  this  will  act  as  a  fulcrum 
and  the  force  of  gravity  will  carry  the  shoulder  backward,  rotating 
the  outer  fragment  out  into  its  normal  relation  with  the  inner.  If 
nowr  a  small  bag  of  shot  were  placed  over  the  inner  fragment,  to 
press  it  dow-n  against  the  outer,  and  the  head  raised  on  a  pillow- 
to  relax  the  sternomastoid,  and  the  upper  extremity  immobilized 
by  proper  bandages;  and  if  the  patient  could  be  induced  to  remain 
in  this  position  for  two  or  three  weeks  until  union  was  fairly  firm, 
then  recovery  without  deformity  probably  would  be  assured.  Cou- 
teaud  (1909)  induced  24  patients  to  submit  to  bed  treatment,  and 
secured  excellent  results  by  letting  the  arm  hang  down  over  the  side 
of  the  bed  for  the  first  two  days,  thus  approximating  the  fragments 
by  keeping  the  pectoralis  major  tense.  But  even  a  young  girl 
anxious  to  preserve  her  neck  from  trifling  deformity  rarely  will  endure 
such  confinement,  and  it  becomes  necessary  to  devise  some  means 
of  ambulatory  treatment;  and  though  by  such  treatment  entire 
absence  of  deformity  rarely  can  be  secured,  yet  recovery  of  function 
usually  is  perfect.      The   indications  are  to   keep  the   scapula  flat 


Fh'AcTCKES  OF  THE  CLAVICLE 


365 


against  the   chest,  thus  rotating  the  shoulder  and  outer  fragment 
away  from  the  chest;  to  steady  the  inner  fragment  by  a  compress; 


Fig.  353. — Dressing  for  fracture  of  clav- 
icle: compress  over  inner  fragment;  arm 
in  Velpeau  position;  fold  of  elbow  and 
chest  protected  by  lint.  Episcopal  Hos- 
pital. 


Fig.  354. — Dressing  for  fracture  of 
clavicle:  arm  fixed  by  adhesive  plas- 
ter.   Episcopal  Hospital. 


and  to  support  the  weight  of  the  upper  extremity.  The  fact  that 
myriad  dressings  have  been  devised  to  meet  these  points  sufficiently 
indicates  that  none  of  them  is  entirely  efficient.  In  children  a  pos- 
terior figure-of-eight  bandage  (Fig.  92),  drawing  the  shoulders  back- 


Fig.  355. — Dressing  for  fracture  of 
clavicle:  application  of  Velpeau  ban- 
dage.   Episcopal  Hospital. 


Fig.  356. — Dressing  for  fracture  of 
clavicle:  Velpeau  bandage  reinforced  by 
figure-of-eight  turns  around  elbow,  shoul- 
der and  axilla.     Episcopal  Hospital. 


ward,  with  a  compress  over  the  inner  fragment,  and  with  the  arm 
supported  in  a  sling,  usually  gives  very  satisfactory  results.    In  adults, 


366 


FRACTURES 


in  whom  the  parts  are  more  difficult  to  fix,  I  prefer  to  use  the  dressing 
indicated  in  the  accompanying  illustrations.  After  strapping  a  com- 
press over  the  inner  fragment,  and  fixing  the  scapula  by  a  broad  strap 
of  adhesive  plaster  passing  across  the  back  to  the  axilla  of  the  sound 
side,  a  piece  of  lint  is  placed  in  the  elbow,  the  axilla  is  dusted  with 


Fig.  357. — Fracture  of  scapula  through  body  and  near  angle.     Age  twenty-four 
years.     Episcopal  Hospital. 

boric  acid  powder,  and  a  large  fold  of  lint  is  fastened  across  the  chest 
(Fig.  353);  the  arm  is  then  slung  to  the  chest  by  a  board  band  of 
adhesive  plaster  (Fig.  354) ;  a  Velpeau  bandage  is  then  applied,  fixing 
the  arm  to  the  chest  (Fig.  355);  this  is  reinforced  by  turns  of  the 
bandage   beneath  the  elbow,  crossing  each  other  over  the  injured 


FRACTURES  OF  THE  SCAPULA  367 

shoulder,  and  passing  beneath  the  axilla  of  the  opposite  side  (Fig.  356) . 
The  last  turns  support  the  upper  extremity  and  pull  the  inner  frag- 
ment down,  forming  a  valuable  addition  to  the  Velpeau  bandage.  This 
dressing  need  not  be  renewed  until  it  comes  loose — usually  not  for  six  or 
seven  days;  and  at  the  end  of  four  weeks  may  be  discontinued,  and 
the  arm  merely  carried  in  a  sling,  its  active  use  being  prohibited 
until  six  weeks  from  the  time  of  the  accident.  Rarely  is  any  after- 
treatment  required,  normal  use  restoring  function  in  a  short  time. 

Scapula. — This  generally  is  broken  by  direct  violence.  Fractures  of 
the  body  of  the  scapula  (Fig.  357)  usually  are  more  or  less  transverse, 
and  the  fragments  are  not  much  separated:  but  by  fixing  the  angle 
with  one  hand,  and  manipulating  the  shoulder  with  the  other,  both 
crepitus  and  mobility  may  be  detected  in  most  cases.  Disability 
rarely  is  marked.  Treatment  consists  in  immobilizing  the  upper 
extremity  for  four  or  five  weeks.  Fractures  of  the  acromion  process 
are  more  frequent  than  those  of  the  body  of  the  bone,  and  are  to 
be  diagnosed  by  persistent  localized  tenderness  following  direct 
injury,  sometimes  by  crepitus,  but  rarely  by  distinct  mobility  unless 
the  line  of  fracture  is  distinctly  posterior  to  the  acromio-clavicular 
joint.  Skiagraphic  confirmation  is  desirable,  and  will  serve  to  dis- 
tinguish this  injury  from  separation  of  the  epiphysis,  which  probably 
is  a  more  frequent  injury,  but  clinically  indistinguishable  from  frac- 
ture. Immobilization  for  about  four  weeks  is  sufficient.  Fracture 
of  the  coracoid  process  may  occur  from  muscular  action,  or  rarely 
from  direct  violence.  It  is  a  rare  injury,  but  usually  may  be  detected 
by  painstaking  examination,  unless  the  patient  is  very  muscular  or 
fat.  The  process  is  pulled  downward  into  the  axilla  by  the  muscles 
attached  to  it,  and  often  may  be  felt  here,  while  it  is  absent  from  its 
normal  site  just  below  the  outer  third  of  the  clavicle.  If  crepitus 
cannot  be  obtained  in  confirmation  of  apparent  displacement  and 
mobility,  a  skiagraph  must  be  relied  on  for  diagnosis.  Fracture 
through  the  surgical  neck  of  the  scapula,  the  line  of  fracture  passing 
through  the  suprascapular  notch  and  detaching  both  the  coracoid 
and  glenoid  processes,  is  a  rare  injury  which  may  be  mistaken  for 
dislocation  of  the  shoulder;  in  dislocation,  however,  the  arm  hangs 
away  from  the  side,  mobility  is  decreased  or  even  absent,  and  no 
crepitus  can  be  obtained;  in  fracture,  though  the  humerus  is  carried 
downward  and  inward  with  the  detached  fragment  by  the  pull  of 
the  axillary  muscles  and  those  attached  to  the  coracoid,  thus  pro- 
ducing a  hollow  beneath  the  acromion,  yet  attentive  examination 
will  show  that  there  is  in  the  axilla  not  the  isolated  head  of  the 
humerus,  but  a  bony  mass  composed  of  coracoid,  glenoid,  and 
humerus,  and  that  the  coracoid  moves  with  the  humerus  and  is 
detached  from  the  scapula.  Moreover,  there  is  crepitus  and  abnormal 
mobility;  and  when  the  deformity  is  reduced,  it  recurs  at  once;  none 
•of  which  phenomena  are  present  in  dislocation.  Finally,  skiagraphic 
evidence  may  be  called  in  aid,  and  usually  will  determine  the  matter 
without  doubt.     Treatment  consists  in  reducing  the  deformity   as 


368 


l  I; ACT U RES 


far  as  possible,  and  immobilizing  the  upper  extremity  as  in  fractures 
of  the  clavicle;  a  folded  towel  or  other  flat  support  should  be  placed 
in  the  axilla  io  aid  in  retaining  the  fragment  in  place.  Reduction 
usually  is  imperfect,  callus  may  be  exuberant,  and  the  restoration 
of  function  may  be  much  delayed,  perhaps  from  involvement  of  the 
suprascapular  nerve. 

Humerus. — It  is  customary  to  divide  these  injuries  into  fractures 
of  the  upper  cud,  those  of  the  shaft,  and  those  of  the  lower  end  of 
the  bone. 


Fig.  358. — Fracture  of  anatomical  neck  of  humerus.     Age  fifty-four  years. 
Episcopal  Hospital. 


Fractures  of  the  Upper  End  of  the  Humerus. — Fracture  of  the 
anatomical  neck  is  a  rare  injury;  the  detached  hemispherical  frag- 
ment is  wholly  or  largely  intra-articular,  and  is  displaced  toward  the 
axilla,  turning  at  right  angles  to  the  shaft  (Fig.  358).  Sometimes 
the  fragment  is  forced  through  the  capsule  of  the  shoulder-joint,  and< 
lies  almost  subcutaneously  in  the  axilla.  Palpation  then  detects 
the  head  in  its  abnormal  position,  while  the  tuberosities  retain  their 


FRACTURES  OF  THE  HUMERUS 


369 


normal  relations  to  the  shaft  of  the  humerus  and  to  the  acromion. 
Crepitus  may  be  elicited  by  pressing  the  detached  head  outward 
against  the  shaft;  but  unless  the  head  is  clearly  palpable  a  positive 
diagnosis  is  very  difficult  without  a  skiagraph.  Most  cases  so  diag- 
nosed turn  out  to  be  high  fractures  of  the  surgical  neck.  If  the  head 
is  displaced  so  far  as  to  be  almost  subcutaneous,  it  is  best  to  remove 
it  by  incision;  function   will  be  much  better  than  if  the  fragment 


Fig.  359. — Separation  of  upper  epiphysis  of  humerus.  Typical  displacement.  Note 
pyramidal  shape  of  upper  end  of  diaphysis,  and  new  formed  bone  beneath  periosteal 
bridge  on  inner  side  of  fracture,  which  has  not  been  reduced.    Age  nine  years. 

remains  as  a  foreign  body  to  excite  periarthritis.  In  cases  where 
displacement  is  slight,  the  treatment  described  below  for  fracture 
of  the  surgical  neck  is  efficient.  Fracture  of  the  greater  tuberosity 
occasionally  occurs  from  muscular  action,  and  more  rarely  still  from 
direct  violence;  a  sprain  fracture  is  a  frequent  lesion  accompanying 
dislocation  of  the  shoulder.  The  fragment  is  drawn  outward,  upward, 
and  backward  by  the  external  rotator  muscles.  Reduction  may  be 
easy,  but  usually  is  very  difficult  to  maintain  even  if  the  humerus  is 
24 


370 


FRACTURES 


dressed  in  adduction.  Hence  operative  fixation  by  periosteal  suture  of 
chromic  catgut  or  by  screw  may  be  advisable.  In  other  cases,  firm 
bandaging  over  a  shoulder-cap  may  keep  the  fragments  in  place.  Sep- 
aration of  the  upper  epiphysis  of  the  humerus:  This  epiphysis  may  be 
separated  at  any  age  until  it  unites  with  the  diaphysis,  not  later  than 
twenty-five  years.  The  injury  is  commonest,  however,  at  or  about 
fifteen  years  of  age,  though  sometimes  it  occurs  as  an  obstetrical  injury. 
The  upper  end  of  the  diaphysis  is  pyramidal  in  shape  (Fig.  359), 
and  the  epiphysis  fits  over  it  like  a  cap.    The  epiphyseal  line  passes 

on  the  surface  of  the  bone  just 
beneath  the  greater  tuberosity, 
irregularly  inward,  being  intra- 
articular on  the  inner  side  of  the 
humerus,  so  that  the  detached  frag- 
ment (the  epiphysis)  is  somewhat 
larger  than  that  in  fracture  of  the 
anatomical  neck,  but  smaller  than 
that  in  fracture  of  the  surgical  neck. 
The  displacement  of  the  epiphysis 
depends  largely  on  muscular  ac- 
tion: the  subscapularis  in  front  and 
the  infraspinatus  and  teres  minor 
behind  draw  the  epiphysis  directly 
inward,  while  the  supraspinatus, 
being  unopposed,  tilts  its  outer 
margin  (the  greater  tuberosity) 
upward;  the  diaphysis  usually,  but 
not  always,  is  drawn  inward  and 
forward,  by  the  muscles  of  the 
axillary  folds,  and  in  typical  cases 
is  prominent  beneath  the  anterior 
fibers  of  the  deltoid.  Fracture  of 
the  surgical  neck  of  the  humerus  is 
the  most  frequent  injury  of  the 
humerus  in  adults,  and  is  produced 
usually  by  a  fall  or  blow  on  the 
outer  surface  of  the  shoulder.  The 
region  included  in  the  surgical  neck 
is  that  from  the  epiphyseal  line 
above,  to  the  upper  border  of  the  insertions  of  the  pectoralis  and  teres 
major  muscles  below.  "High  fractures  of  the  surgical  neck,"  some- 
times called  "fractures  through  the  tuberosities,"  are  in  all  respects 
similar  to  epiphyseal  separations,  but  occur  after  ossification  in  the 
epiphyseal  line.  The  typical  displacement  in  ordinary  fracture  of  the 
surgical  neck  consists  in  the  lower  fragment  being  drawn  inward  by 
the  axillary  muscles,  and  somewhat  upward  by  the  deltoid,  triceps, 
and  muscles  running  from  the  humerus  to  the  coracoid  process.  Unless 
impaction  is  present  the  diagnosis  is  not  difficult;  the  tuberosities  do 


Fig.  360. — Skiagraph  of  impacted 
fracture  of  surgical  neck  of  humerus. 
(See  Fig.  361.)     Episcopal  Hospital. 


FRACTURES  OF  THE  HUMERUS 


371 


not  rotate  with  the  shaft,  and  deformity,  mobility,  and  crepitus  are 
easily  detected. 

Treatment  of  Fractures  of  the  Upper  End  of  the  Humerus. — After 
washing  the  parts  in  alcohol,  a  modified  Fergusson's  dressing  (1842) 
is  applied  as  follows:  a  primary  roller  is  applied  from  the  metacarpus 
up  to  the  site  of  fracture,  with  the  elbow  flexed;  this  prevents  swelling 
of  the  hand  and  forearm  and  adds  much  to  the  patient's  comfort. 
The  fracture  is  then  reduced,  by  traction  downward  in  the  axis  of 
the  body,  manipulating  the  upper  end  of  the  shaft  so  as  to  push 


Fig.  361. — Impacted  fracture  of  surgical  neck  of  humerus  after  reduction  under 
an  anesthetic.     Compare  Fig.  360.     Episcopal  Hospital. 


it  out  and  bring  it  into  contact  with  the  upper  fragment.  Then  a 
moulded  shoulder-cap  of  binder's-board,  well  padded,  is  placed  over 
the  shoulder,  reaching  almost  to  the  elbow,  and  is  held  in  place  by 
a  spica  bandage  of  the  shoulder  (see  Fig.  365).  A  sufficient  amount 
of  raw  cotton  is  then  placed  between  the  arm  and  chest  to  fill  up  the 
natural  hollow,  and  to  keep  the  shaft  of  the  humerus  from  being  dis- 
placed inward.  The  arm  is  then  bandaged  to  the  thorax,  and  a  sling- 
is  applied  to  support  the  wrist.  By  leaving  the  elbow  unsupported, 
thus  gaining  the  advantage  of  extension  by  the  weight  of  the  limb, 


372 


FRACTURES 


there  is  less  danger  of  displacement  of  the  fragments.    This  dressing 
should  be  renewed  about  twice  weekly  for  five  weeks.     Occasionally  it 


Fig.  362.— Fracture  of  humerus  above  insertion  of  deltoid,  lower  fragment  displaced 
outward  and  upward  by  that  muscle.     Episcopal  Hospital. 


will  be  necessary  to  dress  the  arm  in  abduction  in  order  to  secure 
better  apposition  of  the  fragments. 


FRACTURES  OF  THE  HUMERUS 


373 


In  cases  of  fracture  of  the  surgical  neck  impacled  with  deformity 
I  believe  it  usually  is  better,  except  in  the  very  old  or  feeble,  to 
anesthetize  the  patient,  free  the  impaction  (usually  easy)  by  forced 
rotation,  and  reduce  the  deformity  as  far  as  possible  (Figs.  360  and 
361). 

Fractures  of  the  Shaft  of  the  Humerus. — These  may  occur  at  any 
level,  usually  from  direct  violence,  but  occasionally  from  muscular 
action.     In  190G  I  found  references  to  96  such  cases,  mostly  due  to 


Fig.  363. — Fracture  of  lower  third  of  shaft  of  humerus.     Episcopal  Hospital. 


throwing  a  ball,  the  two  ends  of  the  humerus  apparently  being  twisted 
apart  by  violent  rotation  of  the  upper  end,  opposed  by  the  inertia  of 
the  rest  of  the  limb.  Fractures  from  direct  violence  are  more  apt 
to  be  transverse  and  comminuted,  than  those  caused  by  indirect  vio- 
lence, which  are  more  or  less  oblique  or  spiral.  If  the  fracture  is 
above  the  insertion  of  the  deltoid,  there  is  a  tendency  for  the  lower 
fragment  to  be  carried  up  and  out  by  this  muscle;  while  the  upper 
fragment  is  pulled  inward  by  the  axillary  muscles  (Fig.  362);  but  if 
the   fracture   is   below   the  insertion   of  the   deltoid,   the    reverse    is 


::7I 


I  i;  [CTURES 


the  case,  the  uppe/  fragmenl  being  displaced  outward  by  1 1 1< •  deltoid, 
while  the  lower  is  drawn  up  toward  the  axilla  by  the  biceps,  triceps, 


ob 


lialis 


Fig.  364. — Dressing  for  fracture  of  shaft  of 
humerus:  coaptation  splints  around  seat  of  frac- 
ture.    Episcopal  Hospital. 


and  coracooracniaiis.     in    fractures  of   the  lower  third  of  the  shaft, 
which  are  rarer,  there  i-  angular  deformity  forwards,  owing  to  the 

action  of  the  muscles  arising 
from  the  condyles  of  the 
humerus  which  keep  the 
elbow  flexed,  and  thus  bring 
the  upper  end  of  the  lower 
fragment  forward,  as  the  arm 
falls  by  the  side  (Fig  363). 
In  all  fractures  of  the  shaft 
the  diagnosis  is  easily  made, 
and  reduction  is  not  difficult 
to  secure  nor  to  maintain  if 
an  efficient  dressing  is  applied. 
That  which  I  have  used  with 
perfect  satisfaction  is  shown 
in  the  accompanying  illus- 
trations. A  primary  roller 
is  applied  up  to  the  elbow; 
the  arm  is  surrounded  by 
raw  cotton;  three  coaptation 
splints  of  binder's-board  are 
adjusted  around  the  arm,  one  anteriorly,  one  posteriorly,  and  one 
externally  (Fig.  364),  and  are  secured  by  continuing  the  bandage 
up  to  the  axilla;  over  this  a  shoulder-cap  is  next  adjusted  (Fig. 
365),  and  fixed  by  a  spica  of  the  shoulder  (Fig.  366);  the  arm  is 
finally  bandaged  to  the  chest 
and  a  wrist  sling  applied 
leaving  the  elbow  unsup- 
ported to  give  extension  to 
the  seat  of  fracture  (Fig.  367) . 
In  rare  cases  with  overlapping 
of  very  oblique  fractures, 
weight  extension  can  be  ap- 
plied as  an  ambulatory  dress- 
ing (Fig.  368).  If  the  fracture 
is  in  the  lower  third  of  the 
humerus  an  anterior  angular 
splint  (Fig.  369)  may  be  used, 
either  alone,  or  in  addition 
to  the  use  of  a  shoulder-cap; 
but  in  fractures  above  this 
region  any  attempt  to  im- 
mobilize the  elbow  will  result 

in  transferring  every  motion  of  the  forearm  to  the  seat  of  fracture 
in  the  humerus,  and  delayed  union  frequently  will  result. 


Fig.  365.— Dressing  for  fracture  of  shaft  of 
humerus:  shoulder-cap  applied.  Episcopal 
Hospital. 


FRACTURES  OF  THE  HUMERUS 


375 


Fractures  of  the  Lower  End  of  the  Humerus. — These  are  much  more 
frequent  in  children  than  in  adults.     The  usual  cause  in  children 


Fig.  366. — Dressing  for  fracture  of  shaft 
of  humerus,  shoulder-cap  secured  by 
spica  bandage  of  shoulder.  Episcopal 
Hospital. 


Fig.  367. — Dressing  for  fracture  of 
shaft  of  humerus  completed  and  wrist 
sling  applied.     Episcopal  Hospital. 


is  a  fall  on  the  outstretched  hand;  in  adults  such  an  accident  is  more 
apt  to  cause  dislocation  if  the  lesion  occurs  at  the  elbow.      Direct 


Fig.  368. — Weight  extension  for  frac- 
ture of  shaft  of  humerus.  Episcopal 
Hospital. 


Fig.  369. — Anterior   angular  splint   applied 
to  elbow.     Episcopal  Hospital. 


injury,  often  resulting  in  compound  or  comminuted  fractures,  is  a 
more  frequent  cause  of  elbow  fractures  in  adults.    There  are  several 


376 


FRACTURES 


These  are  the  most  frequent  varieties. 


distinct  types  of  fracture  here,  which  may  be  conveniently  classified 
thus  (Fig.  370): 

1.  Supracondylar  Fractures  1 

2.  Diacondylar   Fractures 

3.  External  Condyle 

4.  Epiphyseal  Separation. 

5.  Internal   Condyle. 

().   Intercondylar,  T  or  Y. 

7.  Epitrochlea. 

The  lower  epiphysis  of  the  humerus  is  developed  from  a  number 
of  centres,  and  is  best  studied  in  a  series  of  skiagraphs  of  normal 
elbows:  the  center  for  the  capitellum 
of  the  humerus  appears  during  the 
first  year  of  life,  that  for  the  head  of 
the  radius  becoming  visible  in  the 
sixth  year,  closely  followed  by  that 
for  the  epitrochlea  of  the  humerus. 
These  centers  are  well  shown   in  Fig. 


Fig.  370. — Diagram  to  show  classification  of 
fractures  of  the  lower  end  of  humerus. 


Fig.  371. — Skiagraph  showing  lower 
epiphysis  of  humerus  at  five  years 
and  eleven  months  (antero-posterior). 
Episcopal  Hospital. 


371.  The  center  for  the  trochlea  appears  at  eleven  years,  and  that 
for  the  olecranon  a  little  later.  Fig.  372  is  a  lateral  view  of  the 
normal  elbow  at  eleven  years. 

1.  Supracondylar  Fractures  usually  are  due  to  a  fall  on  the  out- 
stretched hand,  the  elbow  being  suddenly  hyperextended,  and  the 
lower  end  of  the  humerus  torn  off  partly  by  ligamentous  distraction, 
partly  by  the  force  of  the  blow,  which  generally  displaces  the  fragment 
posteriorly.  The  line  of  fracture  is  oblique  from  above  downward  and 
forward  (Fig.  373).  Impaction  is  unusual.  When  the  elbow7  is  extended 
it  is  found  that  lateral  motion  is  possible  between  the  forearm  and 


FRACTURES  OF  THE  ELBOW  377 

arm,  the  "carrying  angle"  is  lost,  anteroposterior  movements  give 
crepitus,  and  often  the  lower  end  of  the  upper  fragment  can  be  felt 


Fig.  372. — Skiagraph  of  lower  epiphysis  of  humerus  at  eleven  years  (lateral). 
Episcopal  Hospital. 


Fig.  373. — Skiagraph  of  supracondylar  fracture  of  humerus;  before  reduction, 
elbow  dressed  on  anterior  right-angled  splint.     Episcopal  Hospital. 


378 


PUACTVRE& 


in  the  bend  of  the  elbow.  The  condyles  retain  their  normal  relation 
with  the  olecranon,  which  is  not  the  ease  in  posterior  dislocation 
at  the  elbow,  for  which  the  deformity  of  fracture  sometimes  is  mis- 
taken. 

L'.  Diacondylar  Fractures  are  transverse  fractures  between  the 
level  of  supracondylar  fractures  and  that  of  the  epiphyseal  line. 
They  usually  follow  a  fall  on  the  extensor  surface  of  the  forearm, 
the  elbow  being  flexed,  and  often  are  impacted.  The  line  of  fracture 
traverses  the  thin  layer  of  bone  separating  the  olecranon  and  coro- 
noid  fossa\     Diagnosis  is  based  on  the  history,  the  signs  of  elbow 


Fig.  374. — Supracondylar  fracture  of  humerus  shown  in  Fig.  373,  after  reduction 
dressed  in  position  of  hyperflexion.     Episcopal  Hospital. 


injury,  and  skiagraphic  examination.  A  rare  form  described  by 
Posadas  (1901)  consists  in  forward  displacement  of  the  lower  fragment 
and  posterior  dislocation  of  the  bones  of  the  forearm. 

3.  Fractures  of  the  External  Condyle  usually  follow  falls  on  the  out- 
stretched hand;  as  the  ulna  does  not  articulate  with  the  hand,  the 
force  is  transmitted  through  the  radius  directly  to  the  external  con- 
dyle, thus  explaining  the  greater  rarity  of  fractures  of  the  internal 
condyle.  The  line  of  fracture  extends  into  the  joint,  somewhere 
between  the   capitellar   and   trochlear   surfaces    (Fig.    375);    lateral 


FRACTURES  OF  THE  ELBOW 


379 


mobility  usually  is  present,  and  crepitus  can  be  detected  cither  in  this 
way  or  by  moving  the  external  condyle  with  thumb  and  finger  directly 


Fig.  375. — Skiagraph  of  fracture  of  external  condyle  of  humerus. 

upon  the  shaft.  Under  the  name  epicondylitis,  Franke  and  Momburg 
(1910)  described  what  corresponds  to  a  sprain-fracture  of  the  external 
epicondyle.  I  have  seen  several 
cases  appparently  of  this  nature. 
4.  Separation  of  the  Entire 
Lower  Epiphysis  may  occur  until 
its  union  with  the  diaphysis, 
from  fifteen  to  seventeen  years, 
but  usually  occurs  before  thirteen 
years  of  age.  The  epiphyseal 
line  is  largely  intra-articular,  pass- 
ing beloiv  the  coronoid  fossa.  A 
small  shell  of  bone  often  is  de- 
tached from  the  diaphysis  also 
(Fig.  376) ;  if  this  is  not  the  case, 
and  the  line  of  fracture  passes 
directly  along  the  epiphyseal  line 
(cartilage),  it  will  not  be  visible 
in  a  skiagraph.  Many  epiphyseal 
separations  are  wrongly  classed  as 
mere  sprains,  because  the  skia- 
graph shows  nothing  abnormal. 
The  trauma  producing  the  injury 
often    is    slight,    and    deformity 

.       .  °  i  c   m  Fig.  3/6. — Skiagraph  of  epiphyseal 

rarelv   IS    present;     but   tailure   to  separation  of  left  humerus. 


380 


FRACTURES 


recognize  the  lesion  may  be  disastrous.  The  diagnosis  is  based  on  a  his- 
tory of  injury,  on  indistinct,  muffled  crepitus,  extreme  pain  on  forced 
extension  and  persistent  localized  tenderness  in  the  flexure  of  the  elbow. 


Fig.  377. — Skiagraph  of  fracture  of  internal  condyle  of  humerus. 

Hospital. 


Episcopal 


5.  Fractures  of  the  Internal  Condyle. — These  are  rare  in  children, 
but  being  caused  usually  by  direct  violence  (falls  on  the  acutely 
flexed  elbow)  are  relatively  more  frequent  in  adults.  The  usual 
line  of  fracture  is  shown  in  Fig.  377.  The  disability  is  extreme,  the 
support  of  the  ulna  being  destroyed:  the  forearm  falls  against  the 
side,  causing  loss  of  the  carrying  angle,  and  the  internal  condyle 
may  be  moved  antero-posteriorly  on  the  shaft. 

6.  Intercondylar  Fractures  are  very  rare,  especially  in  children. 
They  are  caused  by  great  violence,  almost  always  direct,  the  ulna 
being  driven  up  between  the  condyles  and  separating  them  from  each 
other  and  from  the  shaft  (Madelung),  resulting  in  a  Y-fracture;  or  the 
diaphysis  splitting  into  halves  the  fragment  due  to  a  supracondylar 
fracture  (Gurlt,  1862),  resulting  in  a  T-fracture.  The  diagnosis  rests 
on  the  independent  mobility  of  the  condyles  on  each  other  and  on 
the  shaft. 


FRACTURES  OF  THE  ELBOW 


381 


7.  Fractures  of  the  Epitrochlea  (Fig.  378)  often  are  epiphyseal  sepa- 
rations of  this  center,  as  it  does  not  unite  with  the  diaphysis  until  the 


Fig.  378. — Skiagraph  of  fracture  of  epitrochlea  of  humerus.     Episcopal  Hospital. 

eighteenth  year.  The  injury  usually  is  due  to  muscular  or  ligament- 
ous action,  and  is  a  frequent  accompaniment  of  posterior  dislocation 
of  the  elbow. 


Fig.  379. — Fracture  of  capitellum  of  humerus,  from  fall  on  elbow.  Age  thirty-eight 
years.  Patient  under  care  of  Dr.  Jopson  in  University  Hospital.  Fragment  replaced 
by  arthrotomy.     Excellent  result. 

Of  other  rarer  fractures  of  the  lower  end  of  the  humerus,  those  of  the 
capitellum  (Fig.  379)  are  of  most  importance;  the  fragment  usually 


382 


Fli.-U'TURES 


is  displaced  into  the  bend  of  the  elbow,  and  seldom  can  be  replaced 
without  incision. 

Treatment  of  Fractures  of  the  Lower  End  <>f  the  Humerus.  As  these 
fractures  arc  all  close  to  the  joint,  and  many  of  them  wholly  or  in 
part  intra-artieular,  it  is  extremely  important  to  secure  early  and 
accurate  reduction  of  the  fragments,  in  order  to  lessen  the  amount 
of  callus  formed,  and  thus  permit  restoration  of  perfect  function. 
Intelligent  manoeuvres  of  reduction  can  be  undertaken  only  after 
a  correct  diagnosis  has  been  made,  and  I  have  dwelt  upon  the  indi- 
vidual lesions  so  fully  not  because  their  treatment  is  materially 
different,  but  because  accurate 
reduction  must  be  secured  at  the 
earliest  possible  moment;  only  in 
this  way  can  surgeons  hope  to 
remove  the  opprobrium  which  has 
long  attached  to  these  injuries  and 
which  1  believe  is  quite  unnecessary. 


a 


Fig.  380. — Diagram  of  carrying  angle. 
(After  Potter.) 


Fig.  381. — Patient  showing  normal 
earrying-angle  on  right  and  gunstock 
deformity  on  left.     Children's  Hospital. 


Supracondylar  fractures  form  the  large  proportion  of  these  injuries, 
and  I  shall  discuss  the  treatment  of  this  variety  at  greatest  length. 
The  muscles  arising  from  the  condyles  of  the  humerus  are  the  only 
muscles  attached  to  the  fragment,  and  they  tend  to  keep  it  flexed 
on  the  forearm.  Motion  transmitted  from  the  forearm  takes  place 
between  the  fragment  and  the  shaft  of  the  humerus,  not  in  the  elbow- 
joint.  The  fragment  usually  is  displaced  posteriorly.  All  these 
considerations,  as  well  as  clinical  experience,  teach  that  it  is  better 
to  dress  these  injuries  with  the  elbow  flexed.  The  fracture  is  reduced, 
by  hyperextension  of  the  elbow  to  relax  the  triceps,  then  by  extension 


FRACTURES  OF  THE  ELBOW 


3S3 


and  counter-extension  to  bring  the  fragment  forward  into  its  normal 
relation  with  the  shaft.  It  is  kept  reduced  by  hyperflexion  of  the 
elbow  (flexion  as  acute  as  possible),  thus  bringing  the  insertion  of  the 
triceps  anterior  to  the  humerus,  and  making  this  muscle  act  as  a 
sling  in  holding  the  fragment  in  place.  In  order  to  preserve  the 
"carrying  angle,"  which  is  formed  by  an  equal  obliquity  of  the 
articular  surfaces  of  the  humerus  and  the  bones  of  the  forearm  (Fig. 
380),  it  is  extremely  important  to  flex  the  forearm  upon  the  arm 
directly  in  the  sagittal  plane,  and  to  keep  it  in  that  position,  thus 
avoiding  internal  rotation  of  the  lower  fragment.  When  there  is 
loss  of  the  "carrying-angle"  (cubitus  varus,  Fig.  381)  the  forearm 
falls  to  the  outer  side  of  the  arm  when  the  elbow  is  hyperflexed. 
Increase  of  the  "carrying  angle"  (cubitus  valgus)  is  a  less  conspicuous 
and  much  less  disabling  deformity  (Fig.  382). 


Fig.  382. — Patient  showing  cubitus  valgus  after  recovery  from  fracture  of 
internal  condyle.     Episcopal  Hospital. 

Other  fractures  of  the  lower  end  of  the  humerus  must  all  be 
reduced  accurately  by  suitable  manipulations,  which  cannot  be 
described  at  length  here.  All  may  be  kept  reduced  by  dressing  the 
elbow  in  hyperflexion.1  The  method  in  which  this  is  to  be  done  is 
sufficiently  indicated  in  the  accompanying  illustrations:  the  arm 
and  forearm  act  as  splints  to  each  other,  and  when  they  are  bound 
to  each  other  they  may  be  rotated  inward  as  one  bone,  and  the  hand 
slung  around  the  neck  (Figs.  383,  384,  385).     The  elbow  is  dressed 

1  In  the  very  rare  cases  in  which  hyperflexion  does  not  maintain  reduction,  the 
elbow  should  be  dressed  in  the  most  stable  position:  occasionally  this  will  require 
confinement  to  bed  with  weight  traction  in  the  extended  position. 


:;si 


FRACTURES 


Fig.  383. — Dressing  to  maintain  elbow  in  hyperflexion,  first  stage.   Episcopal  Hospital. 


Fig.  384. — Dressing  to  maintain  elbow  Fig.  385. — Dressing  to  maintain  elbow 

in  hyperflexion,   second  stage.     Episcopal         in  hyperflexion,   completed.     Episcopal 
Hospital.  Hospital. 


FRACTURES  OF  THE  ELBOW 


385 


about  twice  weekly,  the  hyperflexion  being  reduced  at  each  dressing 
only  enough  to  permit  washing  the  flexure  of  the  elbow,  and  re-inser- 
tion of  a  fold  of  lint.  At  the  end  of  the  second  week  the  elbow  may 
be  dressed  in  less  acute  flexion,  and  at  the  end  of  four  weeks  may  be 
carried  in  a  sling  for  a  week  or  ten  days.  No  massage  or  passive 
motion  is  necessary  to  restore  function  if  accurate  reduction  has 
been  secured;  but  full  extension  may  not  be  secured  for  several 
months. 

Ulna. — Fractures  of  this  bone  are  caused  mostly  by  direct  violence. 
Fractures  of  the  olecranon,  however,  may  occur  from  muscular  action 
in  sudden  flexion,  or  as  a  "compression"  fracture  in  hyperextension 
of  the  elbow;  unless  the  aponeurotic  insertion  of  the  triceps  is  torn 
widely  there  is  not  much  separation,  but  mobility  and  crepitus  usually 
are  distinct.  In  simple  fractures  operation  rarely  is  indicated,  as 
by  strapping  the  fragment  on  to  an  obtuse  angled  splint  (Fig.  386) 
reduction  usually  is  easy:  even  if  accurate  reduction  is  not  secured 


Fig.  386. — Dressing  fracture  of  olecranon  on  anterior  obtuse  angled  splint, 
omitted  to  show  splint  better.    Episcopal  Hospital. 


Padding 


at  the  first  attempt,  it  is  remarkable  how  much  improvement  in 
position  is  obtained  in  a  few  days.  This  is  one  of  the  few  fractures 
which  prove  an  exception  to  the  general  rule  that  prompt  reduction 
is  necessary  for  recovery  of  good  function.  But  in  cases  where  reduc- 
tion cannot  be  secured  within  a  few  days,  and  in  compound  fractures, 
operation  is  preferable  (Figs.  387  and  388).  Separation  of  the  olecranon 
epiphysis,  which  appears  first  in  a  skiagraph  from  ten  to  eleven  years, 
is  a  rare  injury,  requiring  the  same  treatment  as  fracture.  Fracture 
of  the  coronoid  process  is  a  rare  accompaniment  of  posterior  dis- 
location of  the  elbow,  and  is  to  be  suspected  when  it  is  difficult  to 
maintain  reduction  of  this  lesion.  The  fragment,  which  is  partly 
intra-articular,  and  which  has  the  brachialis  anticus  attached  only  to 
its  base,  seldom  is  much  displaced.  Treatment  consists  in  dressing 
the  elbow  in  hyperflexion  for  a  couple  of  weeks,  and  then  allowing 
gradual  extension.  Fractures  of  the  shaft  of  the  ulna  are  very  dis- 
abling, as  the  ulna  forms  the  main  part  of  the  elbow-joint,  and  through 
25 


386 


FRACTURES 


the  interosseous  ligament  supports  the  radius  and  hand.  Patients 
with  complete  fracture  of  the  ulna  rarely  can  hold  the  forearm  out  for 
an  examination  without  support  from  the  other  hand.  In  the  upper 
part  of  the  shaft  the  displacement  often  is  backward,  owing  to  the 


Fig.  387. — Skiagraph  of  compound  fracture  of  olecranon.     Treated  by  operation. 
(See  Fig.  388.)     Episcopal  Hospital. 


pull  of  the  triceps  (Fig.  390) ;  but  when  the  trauma  has  been  great, 
the  ulna  may  be  displaced  anteriorly,  the  continuation  of  the  force 
causing  forward  dislocation  of  the  head  of  the  radius  (Fig.  457).     In 


Fig.  388. — Skiagraph  of  compound  fracture  of  olecranon,  after  suture  of  aponeurosis 
of  triceps  with  chromic  catgut.    Age  twenty-five  years.     Episcopal  Hospital. 

the  lower  part  of  the  shaft,  the  pronator  quadratus  draws  the  lower 
fragment  against  the  radius,  producing  a  deformity  very  difficult  to 
overcome,  though  sometimes  extreme  abduction  of  the  hand,  by  the 
use  of  a  reverse  Bond  splint   (one  made  for  the  other  hand),  may 


FRACTURES  OF  THE   ULNA 


387 


succeed  (Skillern,  1910).  Green-stick  fractures  of  the  ulna  are  frequent, 
but  these,  as  well  as  complete  breaks  of  the  middle  and  lower  thirds, 
are  frequently  accompanied  by  fracture  of  the  radius.  Fracture 
of  the  styloid  process  of  the  ulna  often  accompanies  fractures  of  the 
lower  end  of  the  radius. 

Owing  to  the  subcutaneous  position  of  the  ulna  the  diagnosis  of 
these  various  fractures  presents  few  difficulties;   and   all   may  be 
treated  by  immobilizing  the  fore- 
arm on   a   straight   splint,   with 
pads  so  adjusted  as  to  overcome 
the  tendency  to  displacement. 

Radius. — Fractures  of  the  head 
of  the  radius  usually  are  caused 
by  a  fall  on  the  over-extended 
palm,  the  force  transmitted 
through  the  radius  making  it 
impinge  with  great  force  on  the 
external  condyle,  and  splitting 
the  head  of  the  radius  into  two 
or  more  parts  (Fig.  3S9).  The 
symptoms  are  persistent  localized 
pain  and  tenderness,  indistinct 
crepitus  on  rotation,  but  rarely 
appreciable  mobility  or  displace- 
ment. A  skiagraph  usually  is 
necessary  for  confirmation,  but 
unless  several  are  taken  in  differ- 
ent planes,  the-  line  of  fracture 
may  not  be  visible.  If  there  is  a 
loose  fragment  it  is  better  to  excise 
it,  as  malunion  or  non-union  is  fre- 
quent. In  most  cases,  however,  it 
is  sufficient  to  immobilize  the  fore- 
arm for  about  four  weeks  in  full 
supination  on  an  anterior  angular 
splint  (Fig.  369).  Fractures  of  the 
neck  of  the  radius  result  from  much 
the  same  causes  as  those  of  its  head,  but  may  accompany  fractures 
of  the  olecranon  from  a  fall  on  the  flexed  forearm;  or  may  be  accom- 
panied by  a  fracture  of  the  shaft  of  the  ulna  (Fig.  390).  These 
fractures  are  apt  to  be  impacted,  and  it  is  not  desirable  to  disturb 
the  impaction  lest  non-union  result,  the  upper  fragment  being  so 
small  as  to  be  uncontrollable.  The  forearm  should  be  dressed  in  full 
supination.  Fractures  of  the  shaft  of  the  radius  are  unusual  except 
when  accompanied  by  fracture  of  the  ulna.  If  the  fracture  is  above 
the  insertion  of  the  pronator  radii  teres,  this  muscle  will  pronate  the 
lower  fragment  while  the  upper  will  be  supinated  and  flexed  by  the 
biceps;  to  reduce  the  deformity  the  forearm  should  be  dressed  in  full 


Fig.  389. — Fracture  of   head  of  radius 
Age  twenty-six  years.    Episcopal  Hospital 


:;ss 


FRACTURES 


supination  (Lonsdale,  1 838) ,  on  an  anterior  splint,  with  the  elbow 
flexed.  If  the  fracture  occurs  below  the  insertion  of  the  pronator 
radii  teres  this  muscle  will  keep  the  upper  fragment  semi-pronated, 
and  the  lower  fragment  should  be  brought  into  that  position  before 
the  splint  is  applied,  and  so  dressed. 


Fig.  390. — Fracture  of  neck  of  radius  complicating  fracture  of  upper  half  of 
ulna.     Episcopal  Hospital. 

Fractures  of  the  Lower  End  of  the  Radius. — The  typical  fracture 
in  this  region,  one  of  the  most  frequent  in  the  entire  body,  is  known 
by  the  name  of  Colles  (1814).  Colles's  Fracture  results  almost  invari- 
ably from  a  fall  on  the  over-extended  palm,  and  the  break  occurs 
about  1  or  2  cm.  above  the  wrist-joint;  the  lower  fragment  is  dis- 
placed toward  the  extensor  surface,  often  being  impacted  into  the 
posterior  surface  of  the  shaft,  the  lower  end  of  which  protrudes 


Fig.  391. — Colles's  fracture  of  radius,  showing  silver-fork  deformity;  recent 
accident  in  patient  of  sixteen  years.     Episcopal  Hospital. 


beneath  the  flexor  tendons.  This  typical  displacement  is  known  as 
the  "silver-fork  deformity,"  and  Fig.  391  shows  that  the  term  is  well 
merited;  often,  however,  deformity  is  much  less  evident.  In  addition 
to  the  antero-posterior  displacement  (Fig.  392) ,  there  usually  is  mod- 
erate radial  deviation  of  the  hand,  rendering  the  head  of  the  ulna 
prominent  (Fig.  393).  A  fracture  of  the  ulnar  styloid  is  a  frequent 
accompaniment.     Crepitus  and  mobility  seldom  are  present,  and  the 


FRACTURES  OF  THE  RADIUS 


389 


diagnosis  usually  is  made  from  the  deformity  and  localized  pain 
and  tenderness;  but  even  in  cases  without  visible  deformity  the 
lesion  should  be  suspected  from  the  nature  of  the  injury.  If  un- 
recognized as  a  recent  injury  the  deformity  may  become  much  more 
evident  in  the  next  twenty-four  hours,  and  the  patient  and  the  surgeon 
whom  he  consults  then, 'are  apt  to  blame  one  who  failed  to  recognize 
a  fracture  the  day  before.      Treatment  consists  in  reduction  as  soon 


Fig.  392.  —  Skiagraph  (lateral 
view)  of  unreduced  Colles's  fracture 
of  radius,  slight  silver-fork  deform- 
ity; duration  three  weeks.  (See 
Fig.   393.)     Episcopal   Hospital. 


Fig.  393. — Skiagraph  (antero-posterior  view) 
of  unreduced  Colles's  fracture  of  radius,  with 
radial  displacement  of  lower  fragment,  and 
fracture  of  the  styloid  process  of  the  ulna.  (See 
Fig.  392.)    Episcopal  Hospital. 


as  possible  after  the  injury  (Fig.  394) :  this  is  accomplished  by  hyperex- 
tension  and  forced  adduction  of  the  lower  fragment  (Fig.  395),  followed 
by  direct  pressure  forward  on  it,  with  counter-pressure  backward  on 
the  lower  end  of  the  upper  fragment.  If  impaction  is  very  firm,  an 
anesthetic  may  be  required.  Usually  more  force  is  necessary  even  in 
cases  of  slight  impaction  than  the  inexperienced  surgeon  expects;  and 
though  failure  to  secure  accurate  reduction  may  not  materially 
interfere   with  use  of  the  hand,  some  deformity   will   remain,   and 


:;:iii 


FRACTURES 


in   many  cases  the   hand   is  permanently  weakened.     Any  dressing 
which  will  hold  the  fragments  in  place  may  then  be  applied,  the 


Fig.  394. — Skiagraph  of  recent  Colles's  fracture  of  radius  and  fracture  of  styloid 
process  of  ulna,  after  reduction.     Episcopal  Hospital. 

forearm  being  in  semi-pronation  or  full  supination,  never  in  complete 
pronation.      Supination   is   the    movement   which    is    most    difficult 


Fig.  395. — Reduction  of  Colles's  fracture,  of  left  radius.     Episcopal  Hospital. 


to  regain,  and  if  the  hand  is  dressed  in  pronation,  it  may  never  be 
regained;  whereas  if  the  fracture  is  put  up  in  full  supination,  all 


FRACTURES  OF  THE  RADIUS 


:;;)[ 


subsequent  activities  of  the  hand  will  be  such  as  to  encourage  return 
of  pronation.  In  cases  where  no  tendency  exists  for  recurrence  of  dis- 
placement, a  straight  posterior  splint  (Fig.  396)  makes  a  comfortable 


Fig.  396, 


-Posterior  splint  for  Colles's  fracture.    Padding  omitted  for  photograph. 
Episcopal  Hospital. 


dressing;  for  the  first  week  this  should  extend  to  the  proximal  inter- 
phalangeal  joints,  but  may  then  be  shortened  to  the  metacarpo- 
phalangeal  articulations.     In  cases  where  reduction  is  difficult  to 


Fig.  397.— Bond's  splint. 

maintain,  I  prefer  to  use  a  Bond  splint"" (Fig.  397),  on  the  flexor 
surface,  with  two  compresses,  one  on  the  dorsal  surface  over  the  lower 
fragment,  and  the  other  on  the  flexor,  to  fill  up  the  natural  concavity 


Fig.  398. — Bond's  splint  for  Colles's  fracture.  Padding  omitted  from  splint,  and 
leather  guard  removed  to  show  compresses;  note  their  form  and  position.  Episcopal 
Hospital. 

of  the  forearm  above  the  wrist,  and  to  retain  the  upper  fragment  in 
proper  position  (Fig.  398).  Splint  support  should  be  continued  for 
three  or  four  weeks. 


392 


FRACTURES 


Other  Fractures  of  the  Lower  End  of  the  Radius.— Barton's  Fracture. 

(lS.'JS)  is  the  inime  given  to  detachment  of  the  dorsal  portion  of  the 
articular  surface  of  the  radius;  diagnosis  without  a  skiagraph  is 
difficult.  Reversed  Colles's  Fracture,  in  which  the  lower  fragment  is 
displaced  toward  the  flexor  surface,  was  described  in  1  <S( >5  by  Cal- 
lender;  the  displacement  was  named  "gardener's  spade  deformity"  by 
Roberts  ( L897).  Chauffeur's  Fracture,  so  named  because  often  received 
while  "cranking"  an  automobile,  may  be  of  various  types,  the  most 
frequent  of  which  is  one  splitting  off  the  outer  surface  of  the  articular 
surface  of  the  radius  through  the  base  of  the  styloid  process  (Fig.  399). 
Separation  of  the  lower  radial  epiphysis  (Fig.  337)  can  be  certainly 
distinguished  from  Colles's  fracture  only  by  radiography.  All  these 
lesions  should  be  treated  by  reduction  of  deformity,  when  present, 
and  immobilization  for  about  four  weeks. 


Fig.   399. — Unreduced  "chauffeur's  fracture"  of  right  radius,  caused  by  kick  of  handle 
while  cranking.     Walter  Reed  General  Hospital. 


Both  Bones  of  the  Forearm. — These  fractures  are  frequent,  either 
from  a  fall  on  the  hand,  or  from  direct  violence.  The  forearm  is  the 
most  frequent  site  of  green-stick  fractures  (Fig.  312);  the  deformity 
usually  is  very  apparent  (Fig.  400),  and  the  treatment  consists  in  reduc- 
ing this,  which  usually  involves  making  the  fracture  complete;  but  as 
this  frequently  is  accomplished  without  much  rupture  of  the  periosteum, 
there  is  little  or  no  tendency  for  the  fragments  to  be  displaced 
subsequently.  The  forearm  is  dressed  as  in  complete  fractures.  In 
these  the  radius  usually  is  broken  a  little  higher  than  the  ulna,  and  one 


FRACTURES  OF  THE  FOREARM 


393 


or  both  bones  may  be  comminuted  (Figs.  401  and  402).    The  diagnosis 
is  easy,  owing  to  the  extreme  mobility.    Reduction  should  be  attempted 


Fig.  400.— Green-stick  fracture  of  both  bones  of  forearm  one  month  after  injury  which 
was  untreated.     Reduced  under  anesthetic.     Children's  Hospital. 

by  fully  supinating  the  forearm,  and  making  extension  and  counter- 
extension  so  as  to  overcome  any  overlapping.     Correct  replacement 


Figs.  401  and  402. — Skiagraphs  of  comminuted  fracture  of  both  bones  of  forearm; 
delayed  union  at  end  of  ten  weeks.  Patient,  aged  fifty-three  years,  then  returned  to 
work  as  blacksmith,  and  two  months  later  union  was  firm.    Episcopal  Hospital. 


of  the  ulnar  fracture  usually  can  be  determined  clinically,  as  this 
bone  is  subcutaneous;  but  the  radius  is  buried  among  so  many  muscles 


394 


FRAC1 i  UE& 


that  a  skiagraph  frequently  is  necessary  to  ascertain  the  position 
of  the  fragments  if  the  fracture  is  above  the  middle  of  the  bone. 
The  forearm  is  then  dressed  in  full  supination  between  two  straight 
splints,  that  on  the  flexor  surface  extending  from  the  bend  of  the 
elbow  to  the  tips  of  the  fingers,  while  the  dorsal  splint  extends  from 
tli.'  olecranon  to  the  wrist  (Fig.  403).  These  splints  should  be  a  little 
wider  than  the  forearm,  so  as  to  prevent  crowding  the  bones  together 
laterally,  and  they  should  be  smoothly  but  thickly  padded.  Apply 
the  splints  with  the  elbow  flexed  to  a  right  angle,  and  make  sure  that 
the  palmar  splint  does  not  compress  the  veins  in  the  bend  of  the 
elbow  and  that  the  dorsal  splint  does  not  cause  a  slough  at  the  back 
of  the  wrist.  A  longitudinal  pad  placed  between  the  bones,  in  the 
effort  to  wedge  them  apart  is  not  only  useless  but  harmful.  Extra  com- 
presses, however,  may  well  be  placed  over  any  of  the  fragments  that 
tend  to  project.  The  splints  are  then  strapped  snugly  around  the 
forearm  and  held  securely  in  place  by  a  roller  bandage.  A  large 
"handkerchief"   or   "triangular"   sling   is   applied,   and  the   forearm 


Fig.  403. — Dressing  for  fracture  of  both  bones  of  forearm.     Padding  omitted.     Note 
length  of  splints.     Forearm  in  full  supination.     Episcopal  Hospital. 


carried  against  the  chest,  but  always  in  full  supination.  I  urge  the 
employment  of  this  position  not  only  because  supination  is  the  most 
difficult  part  of  rotation  to  regain,  and  because  the  upper  fragment 
of  the  radius  usually  is  kept  in  supination  by  the  biceps,  but  because 
I  have  found,  if  the  forearm  is  dressed  in  mid-pronation,  as  is  com- 
monly advised  now,  that  the  fragments  sag  by  the  force  of  gravity, 
and  the  patient  recovers  not  only  with  lost  supination,  but  with 
angular  deformity  of  both  bones  toward  the  ulnar  side.  If  attempt 
is  made  to  correct  this  deformity  by  adjusting  a  coaptation  splint 
over  the  angular  projection  of  the  ulna,  this  may  be  overcome,  but 
the  surgeon  will  succeed  merely  in  forcing  the  ulna  nearer  the  radius, 
which  cannot  be  influenced  by  such  an  appliance,  and  the  disability 
as  regards  rotation  will  be  increased.  It  often  is  exceedingly  difficult 
to  keep  these  fractures  even  approximately  reduced  during  the 
first  week;  but  usually  a  little  better  position  can  be  secured  at  each 
dressing,  and  when  the  ends  of  the  bones  begin  to  become  sticky, 
during  the  second  week,  it  will  be  found  that  deformity  daily  becomes 
less,  and  what  looked  at  first  like  a  hopeless  case,  will  result  in  a  very 


FRACTURES  OF  THE  FOREARM 


395 


useful  arm,  and  one  with  slight  or  no  visible  deformity.  Skiagraphs 
are  valuable  and  interesting,  but  I  advise  the  inexperienced  not  to 
be    terrified    by  the  appearance  of  the  bones  in  a  skiagraph  into 


Fig.  404. — Fracture  of  both  bones  of  forearm.     Lateral  and  antero-posterior  views 
after  first  dressing.     See  Fig.  405.     Episcopal  Hospital. 

thinking  that  only  operative  treatment  can  give  his  patient  a  good 
result.  If  he  uses  the  eyes  in  the  ends  of  his  fingers,  he  will  secure 
by   conservative    means    quite    as    good,    and    in    many    cases    a 


Fig.  405. — Same  case  as  Fig.  404.    Lateral  and  antero-posterior  views  four  months 
after  injury    Slight  callus  palpable.     No  visible  deformity.     Perfect  function. 


much  better  result  than  by  operation,  and  in  a  shorter  time  (Figs. 
404  and  405). 


396 


FRACTURES 


Carpus. — Of  these  fractures,  that  of  the  scaphoid  is  least  unusual, 
resulting  usually  from  a  fall  on  the  thenar  eminence;  the  diagnosis 
is  made  from  tenderness  in  the  "anatomical  snuffbox,"  sometimes 
by  dorsal  displacement  of  one  of  the  fragments,  and  effusion  in  the 
radio-carpal  joint.  Confirmation  by  a  skiagraph  is  advisable  (Figs. 
4(H)  and  407).  Treatment  consists  in  excision  of  an  irreducible  frag- 
ment, and  in  immobilization  on  a  palmar  splint  for  three  or  four  weeks 
for  those  cases  without  deformity.  In  cases  of  non-union  with  disa- 
bility excision  of  one  or  both  fragments  gives  good  results. 


Fig.  406 — Fracture  of  carpal  scaphoid 
from  fall  on  hand  from  a  height  of  several 
feet.     Orthopaedic  Hospital. 


Fig 


407. — Same  case  as  Fig.  406;  six  weeks 
later,  fracture  united. 


Metacarpus. — Fractures  of  the  metacarpals  result  usually  from 
direct  violence  (prize-fighting,  etc.);  the  displacement  is  angular, 
toward  the  extensor  surface,  and  may  be  difficult  to  keep  reduced. 
The  hand  may  be  dressed  on  a  palmar  splint,  the  palm  being  well 
padded;  or  may  be  bandaged  over  a  firm  roller,  the  tension  on  the 
extensor  tendons  preventing  deformity  (Fig.  408).  Fracture  of  the  base 
of  the  thumb  metacarpal  (Bennett,  1886),  may  resemble  a  subluxation 
of  that  bone  (Fig.  409). 

Phalanges. — Fractures  of  these  usually  are  caused  by  direct 
violence,  often  being  compound  and  requiring  amputation.  Simple 
fractures  are  dressed  on  antero-posterior  splints  (Fig.  410)  for  about 


FRACTURES  OF  THE  PHALANGES 


397 


Fig.  408. — Dressing  for  fracture  of  metacarpals.     Hand  bandaged  over  a  roller. 
Episcopal  Hospital. 


Fig.  409.— Fracture  of  base  of  thumb  metacarpal.     Episcopal  Hospital. 


398 


FRACTURES 


three  weeks.  If  angular  deformity  toward  the  flexor  surface  persists, 
due  to  the  pull  of  the  interossei,  the  fingers  may  be  dressed  in  flexion 
over  a   roller  bandage. 


Fig.  410.    -Dressing  for  fracture  of  the  phalanges.     Episcopal  Hospital. 

FRACTURES  OF  THE  LOWER  EXTREMITY. 

Femur.  -This  is  the  most  serious  fracture  of  the  extremities  that  a 
patient  can  suffer,  but  fortunately  it  is  less  serious  in  children,  in 
whom  it  is  more  frequent,  than  in  adults.  In  adults  fractures  of 
the  leg  are  much  more  frequent  than  in  children.  The  fractures  of 
the  femur  may  be  grouped  into  those  of  the  upper  end,  those  of  the 
shaftj  and  those  of  the  lower  end. 


Fig.  411. — Fracture  of  neck  of  femur  close  to  its  head.     Episcopal  Hospital. 

Fractures  of  the  Upper  End  of  the  Femur. — Fractures  of  the  neck 
of  the  femur  ("fracture  of  the   hip")  are  more  common  in  adults, 


FRACTURES  OF  THE  FEMUR 


399 


especially  those  past  sixty-five  years  of  age,  than  in  children.  The 
trauma  in  the  aged  often  is  trivial  as  their  bones  are  more  brittle; 
some  cases  are  caused  by  a  mere  twist  of  the  leg,  catching  it  in  a 
fold  of  the  carpet,  on  an  uneven  paving  stone,  etc.,  or  by  sitting  down 
suddenly.  Such  injuries  usually  produce  a  fracture  of  the  neck  close  to 
the  head  (intracapsular),  and  seldom  are  impacted  (Fig.  411).  Falls 
on  the  great  trochanter,  especially  in  patients  under  seventy  years  of 
age,  are  more  apt  to  result  in  an  impacted  fracture  close  to  the  trochan- 
ter (Fig.  412),  which  is  at  least  partly  extracapsular.  In  children, 
also,  fractures  of  the  neck  of  the  femur  usually  are  impacted,  or 


Fig.  412. — Impacted  fracture  at  base  of  neck  of  femur. 
Episcopal  Hospital. 


Age  sixty-five  years. 


partial;  or  an  epiphyseal  separation  of  the  head  may  occur.  In 
impacted  fractures,  the  impaction  occurs  chiefly  at  the  expense  of 
the  posterior  part  of  the  neck,  the  shaft  of  the  femur  being  rotated 
outward  as  the  posterior  margins  of  the  fragments  are  driven  together. 
Symptoms. — Muscular  spasm  is  prominent,  and  this,  with  local- 
ized pain  and  tenderness,  sometimes  are  alone  sufficient  to  warrant 
the  diagnosis  in  the  aged.  In  unimpacted  fractures  the  patient 
usually  is  unable  to  raise  the  limb  from  the  bed;  deformity  is  char- 
acteristic, consisting  in  eversion  of  the  lower  extremity,  the  fibular 
side  of  the  foot  lying  on  the  bed;  and  there  is  moderate  shortening 
(2  to  4  cm.),  which  frequently  increases  during  the  second  day.     In 


101) 


FRACTURES 


impacted  fractures  the  shortening  may  not  exceed  1  cm.  Normally 
when  the  thigh  is  flexed  the  great  trochanter  lies  on  a  line  drawn 
from  the  anterior  superior  spine  of  the  ilium  to  the  tuber  ischii 
(Nilaton's  line,  IN  17);  hut  when  there  is  fracture  of  the  neck  of  the 
femur  the  muscles  (ilio-psoas,  adductors,  hamstrings,  glutei)  passing 
from  the  pelvis  to  the  shaft  pull  the  lower  fragment  up,  so  that  the 
trochanter  lies  above  this  line,  and  approaches  or  even  ascends  above 
a  plumb  line  dropped  from  the  anterior  superior  spine  when  the  patient 
is  lying  supine  (Bryant's  line,  1879);  the  relation  of  the  trochanter  to 
Xelaton's  and  Bryant's  lines  on  the  two  sides  should  be  compared  (Figs. 
413  and  414).  The  trochanter  is  less  prominent  on  the  injured  side 
owing  to  the  loss  of  support  from  the  neck  of  the  bone,  and  by  placing 
the  tips  of  the  fingers  between  the  trochanter  and  iliac  crest  it  will 
be  found  that  the  fascia  lata  on  the  injured  side  is  relaxed  (Allis's 
sign,  1877).  Sometimes  from  the  shortening  a  fold  or  wrinkle  is 
formed  over  the  tendo  patella?,  and  can  be  smoothed  out  by  making 


Fig.  413. — Nelaton's  line;  passes  from 
anterior  superior  spine  of  ilium  to  tuber 
ischii  and  crosses  tip  of  great  trochanter 
of  femur,  when  thigh  is  partly  flexed. 


Fig.  414.— Bryant's  line,  a  plumb  line 
from  anterior  superior  spine  of  ilium, 
patient  supine.     Orthopaedic  Hospital. 


extension  (Cleemann,  1876).  In  cases  without  impaction,  mobility 
is  present:  this  may  be  detected  by  rotating  the  entire  limb,  when 
it  will  be  found  to  have  a  greater  range  of  motion  than  the  uninjured 
limb;  and  by  pushing  upward  and  pulling  downward  in  the  axis 
of  the  limb,  the  greater  trochanter  will  be  found  to  slide  up  and 
down  on  the  pelvis;  During  these  manoeuvres  crepitus  usually  is 
elicited.  By  palpating  the  trochanter  as  the  limb  is  rotated,  it  will 
be  found  to  rotate  in  the  arc  of  a  smaller  circle  than  the  trochanter 
on  the  uninjured  side;  this  is  because  the  center  of  motion  is  trans- 
ferred from  the  acetabulum  to  the  seat  of  fracture.  Usually  there  is 
an  abnormal  fulness  over  the  head  of  the  femur  (just  below  Poupart's 
ligament,  beneath  or  immediately  external  to  the  femoral  artery) 
owing  to  effusion  in  the  joint  and  the  external  rotation  of  the  outer 
fragment. 

Diagnosis  rarely  is  difficult  in  the  adult,  attention  being  paid 
to  the  history  of  injury,  even  if  slight,  and  to  the  cardinal  physical 
signs,  shortening,  eversion,  and  crepitus.     In  cases  with  impaction, 


FRACTURES  OF  THE  FEMUR  401 

where  mobility  and  crepitus  are  absent,  and  where  eversion  and 
shortening  are  slight,  the  diagnosis  is  less  certain;  but  the  cautious 
surgeon  will  treat  all  suspected  injuries  of  the  hip  in  the  aged  as  if 
they  were  fractures  until  the  contrary  is  proved.  The  impaction 
may  be  slight,  and  is  apt  to  be  released  spontaneously.  A  skiagraph  is 
very  useful  in  such  cases,  and  as  well  in  children,  in  whom  green-stick 
fracture,  epiphyseal  separation,  or  fracture  with  impaction,  are  the 
usual  lesions.  Frequently  the  true  nature  of  the  case  is  not  recognized 
in  children,  and  the  surgeon  sees  the  patient  first  when  traumatic 
coxa  vara  (p.  586)  has  developed. 

Prognosis. — In  the  aged,  death  occurs  from  shock,  pneumonia, 
bed-sores,  exhaustion,  etc.,  in  about  one  out  of  four  cases  during 
the  first  year  after  injury;  in  those  who  recover,  a  useful  limb  results 
in  about  60  per  cent,  of  cases;  nearly  all  of  these  will  have  a  limp 
and  slight  eversion  (Ashhurst  and  Newell,  1908).  In  children  there 
is  little  disability  though  marked  degrees  of  coxa  vara  may  require 
subsequent  treatment. 

Treatment. — In  the  aged,  constitutional  treatment  often  is  more 
important  than  the  local;  these  patients  should  not  be  kept  in  bed 
after  the  first  shock  of  the  accident  and  the  acutest  symptoms  have 
subsided,  unless  they  continue  to  improve.  Get  them  up  in  a  chair 
a  few  hours  each  day  so  soon  as  they  seem  to  be  losing  ground.  Watch 
for  and  guard  against  hypostatic  congestion  of  the  lungs  and  bed- 
sores. Keep  the  bowels  open  and  the  kidneys  active.  Stimulate 
the  appetite. 

The  usual  teaching  is  not  to  disturb  an  impaction  if  one  is  present; 
and  a  very  good  rule  it  is  in  many  cases;  but  in  children  this  does 
not  hold  good  if  there  is  deformity,  and  in  such  cases  even  in  robust 
adults  (even  up  to  sixty-five  years),  it  is  a  question  whether  a  more 
useful  limb  might  not  be  secured  by  breaking  up  the  impaction 
and  dressing  the  limb  in  extreme  abduction  as  described  below. 
Impaction  is  usual  in  fractures  near  the  trochanters,  and  non- 
union would  not  be  apt  to  occur  if  the  impaction  were  reduced  in 
vigorous  adults.  But  in  aged  persons,  or  speaking  generally,  in  those 
past  seventy  years,  it  is  far  better  to  let  the  fracture  stay  impacted, 
even  if  there  is  deformity,  since  it  is  better  to  have  them  walking 
about  with  a  limp  and  shortening  and  eversion,  than  to  have  them 
dependent  on  crutches  or  even  a  cane,  as  is  almost  always  the  case 
if  non-union  is  present.  Delbet  (1908)  suggested  producing  artificial 
impaction  in  recent  fractures,  and  Cotton  (1910)  has  secured  it  in  a 
number  of  cases  by  hammering  on  the  trochanter  with  a  mallet.  I 
find  it  sufficient  to  abduct  the  limb  until  a  crunch  is  heard,  evidencing 
the  occurrence  of  impaction. 

Unimpacted  fractures  may  be  reduced  by  flexing  the  thigh  on 
the  pelvis  to  a  right  angle  (to  relax  the  iliopsoas  which  may  press 
the  capsule  between  the  fragments),  then  making  vertical  traction 
upward  on  the  thigh,  and  finally  bringing  the  thigh  down  to  the  plane 
of  the  bed  in  moderate  internal  rotation  and  abduction  as  great  as 
26 


Ii  12 


FRACTURES 


possible.  This  last  manoeuvre  makes  the  anterior  portion  of  the 
capsule  tense,  and  wedges  the  outer  fragment  against  the  detached 
head  lying  loose  in  the  acetabulum  by  keeping  the  iliopsoas  tense  across 

the  anterior  part  of  the  joint. 
Whitman,  who  since  1897  has 
advocated  the  abduction  treat- 
ment of  fractures  of  the  femoral 
neck,  encases  the  entire  lower 
extremity  and  pelvis  in  plaster 
of  Paris  (Fig.  415);  this  is 
usually  well  borne  by  old  people, 
and  their  bed  care  is  much  sim- 
plified by  the  ease  with  which 
they  may  be  turned.  The  head 
of  the  bed  should  be  kept  ele- 
vated to  guard  against  hypo- 
static pneumonia.  A  method 
of  lateral  and  longitudinal  trac- 
tion, was  described  accurately 
in  1869  by  Phillips,  was  taught 
for  many  years  by  Maxwell, 
and  has  been  revived,  system- 
atized, and  popularized,  by  Ruth 
(1899).  It  is  substantially  iden- 
tical with  Bardenheuer's  method 
(1889),  and  will  give  good  results 
in  cases  of  fracture  at  the  base 
of  the  neck,  whether  impacted  or  not.  The  fracture  is  reduced  as 
described  above,  and  in  addition  to  the  longitudinal  extension  (Fig. 


Fig.  415. — Abduction  cast  for  separation 
of  epiphysis  of  head  of  femur;  age  fourteen 
years.  Cast  has  been  cut  off  foot  recently 
to  facilitate  walking.     Episcopal  Hospital. 


Fig.  416. — Applying  Buck's  adhesive  plaster  extension  apparatus  for  fracture  of  femur. 

Orthopaedic  Hospital. 


410)  lateral  traction  also  is  made  on  the  upper  part  of  the  thigh. 
The  longitudinal  traction  should  be  strong  enough  to  overcome 
shortening,  and  about  two-thirds  as  much  weight  should  be  used  in 


FRACTURES  OF  THE  FEMUR  403 

lateral  traction  (Fig.  417).  The  lateral  traction,  which  should  draw 
the  femur  slightly  away  from  the  plane  of  the  bed  as  well  as  laterally, 
overcomes   outward   rotation  and  keeps  the  capsule  of  the  hip-joint 


Fig.  417. — Longitudinal  and  lateral  traction  for  fracture  of  neck  of  femur.  Note 
also  use  of  Volkmann's  sliding  foot  splint  to  prevent  rotation  of  limb  and  to  diminish 
friction.     Episcopal  Hospital. 


Fig.  418. — Fracture  through  trochanters  of  femur;  rare  and  atypical  line  of  fracture. 

Episcopal  Hospital. 


101 


FRACTURES 


tense,  preventing  it  from  falling  in  between  the  fragments.  Every 
two  or  three  days  the  longitudinal  traction  should  be  substituted  by 
traction  with  the  hands  upon  the  thigh,  and  the  knee  should  be  flexed 
gently  through  about  30  degrees  to  prevent  stiffness.  Union  is  good 
at  the  end  of  four  weeks.  Ruth  found  in  1907  that  among  a  total  of 
72  cases  treated  by  this  method  there  had  been  no  failure  of  union  in 
patients  under  eighty  years,  no  failure  to  secure  a  useful  limb  under 
seventy  years  of  age,  and  in  those  past  eighty  years  of  age,  success  was 
obtained  in  over  GO  per  cent,  of  cases.  Impacted  fractures  are  treated 
in  the  same  way,  but  less  weight  is  required. 

Fractures  through  the  trochanters  of  the  femur  are  not  very  rare, 
usually  are  due  to  great  direct  violence,  and  often  are  impacted. 

Three  grades  of  this  injury  may  be 
recognized  (Ashhurst,  1913):  the  first  is 
little  more  than  an  impacted  fracture 
at  the  base  of  the  neck;  in  the  next,  the 
neck  penetrates  the  trochanteric  region 
further,  and  a  splitting  fracture  occurs; 
and  in  the  severest  grade  the  trochanteric 
region  is  entirely  shattered.  A  linear 
fracture  between  the  level  of  the  trochan- 
ters is  quite  rare  (Fig.  418).  In  most 
cases  the  lesser  trochanter  is  fractured 
(Fig.  419).  Metcalf  (1915)  collected  17 
cases  of  isolated  fracture  of  the  lesser 
trochanter.  Isolated  fracture  of  the  great 
trochanter  occurs,  and  may  require  perios- 
teal suture  to  maintain  reduction. 

Fractures  of  the  Shaft  of  the  Femur. — 
These  are  much  more  common  in  children 
and  young  adults  than  in  old  people, 
and  usually  are  due  to  direct  violence. 
There  are  three  main  types :  (1)  Fracture 
below  the  trochanters.  The  upper  fragment  is  flexed  by  the  iliopsoas; 
and  rotated  outward  by  the  gluteus  maximus  and  the  short  external 
rotators.  The  lower  end  of  the  upper  fragment  often  is  felt  as  a  sharp 
projection  in  Scarpa's  triangle;  while  the  lowrer  fragment  is  drawn 
upward  and  inward  by  the  adductors  (Fig.  317).  The  leg  rolls  out- 
ward from  its  own  weight,  and  shortening  is  marked.  Crepitus  and 
abnormal  mobility  are  easily  detected.  (2)  Fracture  of  the  middle  of  the 
shaft,  often  oblique  (Fig.  317),  is  attended  by  more  shortening  than 
any  fracture  in  the  body,  sometimes  as  much  as  12  cm.  (five  inches); 
the  leg  rolls  outward,  there  is  flail-like  motion  and  marked  crepitus 
at  the  seat  of  fracture;  the  lower  fragment  is  drawn  up  and  in  by  the 
adductors  and  hamstrings,  and  the  upper  fragment  projects  anteriorly 
(Fig.  421).  (3)  Supracondylar  fractures  are  characterized  by  posterior 
displacement  of  the  lower  fragment  which  is  kept  flexed  at  the  knee 
by  the  gastrocnemius   (Fig.  423);  and  by  anterior  projection  of  the 


Fig.  419. — A  common  type  of 
fracture  through  the  trochanters: 
fracture  at  base  of  neck  of  femur 
(impacted) ;  with  separation  of 
lesser  trochanter.  Age  forty-five 
years.     Episcopal  Hospital. 


FRACTURES  OF  THE  FEMUR 


405 


upper  fragment,  which  may  be  embedded  in  the  rectus  muscle.  The 
diagnosis  of  these  various  types  of  fracture  of  the  shaft  is  riot  difficult, 
since  the  displacement  is  fairly  constant,  and  if  deformity  is  great  the 
ends  of  the  fragments  usually  can  be  palpated  even  in  very  muscular 
limbs. 

Prognosis. — The  general  mortality  is  about  15  per  cent.;  90  per  cent, 
of  those  who  recover  under  conservative  treatment  secure  entirely 
useful  limbs,  but  about  one  out  of  three  of  these  will  have  a  limp, 


Fig.  420. — Fracture  of  femur  below  trochanters.    Episcopal  Hospital. 

and  only  about  one  patient  out  of  four  will  have  no  shortening  (Ash- 
hurst  and  Newell,  1908).  Though  many  surgeons  urge  the  operative 
treatment  of  recent  fractures  of  the  femur  as  a  routine,  I  am  not 
aware  that  they  have  published  figures  demonstrating  even  as  good 
results  as  the  above. 

Treatment. — Reduction  of  the  fracture  is  difficult,  but  probably 
could  be  more  often  obtained  if  the  patient  was  anesthetized.  Weight 
extension  sheuld  be  applied  in  sufficient  amount  to  overcome  shorten- 
ing.    Ochsner  has  found  that  if  the  adhesive  plaster  is  carried  up  to 


106 


FRACTURES 


the  groin,  irrespective  of  the  height  of  the  fracture,  weight  extension 
is  much  more  efficacious.  The  full  amount  of  weight  necessary  should 
be  applied  during  the  first  day  or  two  after  the  accident,  since  shorten- 
ing becomes  more  difficult  to  overcome  the  longer  it  lasts.  By  raising 
the  foot  of  the  bed  from  4  to  <>  inches,  counter-extension  is  provided  by 
the  weight  of  the  patient's  body.    A  sling  around  the  perineum  attached 


Fig.  421. — Skiagraph  of  transverse 
fracture  of  shaft  of  femur.  Best  posi- 
tion obtainable  after  etherization  and 
attempts  at  reduction  with  extension 
by  compound  pulley.  Femur  plated. 
(See  Fig.  422.)  Age  twenty-three 
years.     Episcopal  Hospital. 


Fig.  422. — Skiagraph  of  patient  shown  in 
Fig.  421,  three  months  after  fracture  of  femur 
was  plated.  Excellent  result,  with  no  limitat- 
ion of  motion.  Plate  still  in  place  nine  years 
after  operation.     Episcopal  Hospital. 


to  the  head  of  the  bed  often  is  desirable  for  counter-traction.  If  neces- 
sary the  patient  is  anesthetized  {usually  on  the  second  day)  and,  short- 
ening being  -overcome  by  the  weights,  the  fragments  are  manipu- 
lated into  as  accurate  apposition  as  possible.  Extension  by  means 
of  the  compound  pulley  may  be  necessary  in  very  muscular  adults, 
the  extension  being  made  by  means  of  a  clove  hitch  applied  above  the 
knee  (Fig.  424).     Sometimes  angulation  of  the  fragments  over  the 


FRACTURES  OF  THE  FEMlll 


407 


forearm  will  enable  the  surgeon  to  secure  end-to-end  apposition. 
Absolute  reposition  rarely  can  be  obtained,  and  is  not  necessary 
to  secure  a  useful  limb.  In 
subtrochanteric  fractures  it  may 
be  necessary  to  raise  the  lower 
fragment  on  a  double-inclined 
plane,  in  order  to  approximate 
it  to  the  upper  (Fig.  425);  and 
in  supracondylar  fractures  it 
always  is  advisable  to  flex  the 
knee  (rarely  to  divide  the  tendo 
Achillis)  so  as  to  relax  the  gas- 
trocnemius muscle.  In  fracture 
of  the  middle  of  the  shaft  the 
thigh  is  dressed  in  the  extended 
position,  and  the  seat  of  fracture 
always  should  be  supported  by 
coaptation  splints.  Rotation 
outward  of  the  lower  fragment 
is  prevented  by  the  use  of  Volk- 
mann's  sliding  splint  (1882)  or 
similar  device  (Fig.  417).  A 
long  external  splint  (Liston, 
1837),  well  padded,  extending 
from  the  axilla  to  below  the 
foot,  and  bandaged  firmly  to 
the  entire  lower  extremity  and 
pelvis,  will  prevent  outward 
angulation  of  the  fracture;  and 

the  use  of  a  shot  bag  will   Over-  FlG.  423.— Skiagraph    of   fracture    above 

Come        anterior        displacement.      condyles  of  femur.     Lower  fragment  drawn 
o  e  e     i    7  j    7  j        .«•        /  backward  bv  action  of  gastrocnemius.    Epis- 

.Some  torm  of  skeletal  traction  (p.     copai  Hospital. 


Fig.  424. — Clove  hitch  and  compound  pulley  for  reduction  of  fractures  of  the  femur 
under  anesthesia.  Counter-extension  by  a  sheet  tied  to  the  head  of  the  bed.  Episcopal 
Hospital. 


IDS 


FRACTURES 


340)  may  be  advisable.  In  children,  Hamilton's  splint  (1860)  facili- 
tates moving  the  patient,  as  it  fixes  hot h  lower  extremities  by  long 
external  splints  fastened  together  by  a  eross-har  below  the  feet, 
through  which  passes  the  cord  carrying  the  weighl  extension. 

Immobilization  in  adults  should  be  continued  for  six  to  eight  weeks, 
but  after  the  first  four  weeks  very  light  massage  is  permissible, 
above  and  below  the  fracture.  Weight-bearing  should  not  be  at- 
tempted for  eight  or  ten  weeks  after  the  injury — in  general,  not  until 
four  weeks  after  union  seems  solid,  as  subsequent  shortening  with 
angular  deformity  is  a  sad  consequence  of  too  early  efforts  to  walk. 
In  very  young  children  weight-bearing  may  be  resumed  in  six  or  seven 
weeks. 


Fig.  425. — Double  inclined  plane,  with  weight  extension  for  fracture  of  femur 
below  the  lesser  trochanter.     Episcopal  Hospital. 

Fractures  of  the  Lower  End  of  the  Femur. — Epiphyseal  separation 
occurs  oftenest  from  six  to  ten  years  of  age,  usually  from  hyper- 
extension  or  a  twisting  injury,  as  from  having  the  leg  caught  in  a 
revolving  wheel.  The  epiphysis  usually  is  displaced  forward  (Fig. 
426).  Reduction  may  be  difficult,  and  is  best  maintained  by  dressing 
the  knee  in  flexion.  Fracture  of  one  or  other  condyle,  usually  the 
external,  is  more  frequent  in  children  than  adults,  and  occurs  mostly 
from  direct  violence.  There  is  mobility  of  the  fragment,  and  lateral 
mobility  in  the  knee,  in  addition  to  crepitus,  localized  pain,  etc. 
Effusion,  perhaps  bloody,  often  occurs  into  the  joint.  Treatment 
consists  in  immobilization  with  weight-extension  or  gypsum  case, 
in  good  position,  for  four  or  five  weeks.  Use  of  the  limb  should  be 
gradually  resumed. 

Patella. — If  these  fractures  occur  from  direct  violence  there  may 
be  comminution,  but  there  seldom  is  much  separation  of  the  frag- 
ments unless  the  lateral  expansions  of  the  quadriceps  tendon  are 
ruptured;  in  fracture  from  muscular  action,  however,  which  is  the 


FRACTURES  OF  THE  PATELLA 


409 


usual   form,   this  fibrous  expansion   is   widely  torn,   as  the  fracture 

takes  place  by  sudden  flexion  of  the  knee,  and  the  tense  quadriceps 

breaks  the  patella  over  the  condyles 

as   an   over-bent   lever.     The    bone 

usually    gives     way     more    or    less 

transversely,     the    lower    fragment 

being  smaller. 

Diagnosis.  —  Diagnosis  is  easy, 
owing  to  separation  between  the 
fragments,  free  mobility,  and  crepi- 
tus. If  the  quadriceps  expansion  is 
not  torn,  the  patient  may  still  be 
able  to  walk;  usually  he  is  entirely 
disabled.  I  have  seen,  however,  a 
few  cases  of  subperiosteal  fracture, 
demonstrated  by  skiagraphs,  in 
which  there  was  no  disability. 

Treatment.  —  Treatment  in  most 
cases  is  operative,  as  it  is  difficult 
to  secure  good  apposition  without 
suture  of  the  fragments.  But  in  the 
aged,  or  those  with  visceral  disease, 
operation  is  much  more  of  a  risk, 
and  conservative  treatment  may  se- 
cure a  very  useful  leg.  The  limb  is 
dressed  on  an  inclined  plane  (Fig. 
427),  thus  relaxing  the  quadriceps 
muscle,  and  the  fragments  are  ap- 
proximated by   straps    of    adhesive 

,                          ,  "        .        ,                      p  £  Iig.  42o. — Separation  of  lower  epi- 

plaster,   much  as  in  the  Case   Ot   trac-  physis  of  femur.     Reduced  under  ether 

tUred   Olecranon;   the    plaster    should  and  knee  dressed  in  flexion  on  double 

'               r   .            .  inclined   plane.      Dr.    H.    (  .    Dearer  s 

be    readjusted    every   tew  days  to      case.    Episcopal  Hospital. 


Fig.  427. — Fracture  of  patella,  dressed  on  inclined  plane.     Episcopal  Hospital. 


Ill) 


FRACTURES 


keep  the  fragments  as  close  together  as  possible,  and  to  avoid  everting 
them.     This  dressing  is  continued  for  six  weeks.     Even  if  only  fibrous 


FlQ.  428. — Fracture  of  patella  with  wide  separation  of  fragments,  showing  power  of  full 
extension  six  years  after  injury.     No  operation  was  done.     Episcopal  Hospital. 

union  results,  and  if  after  getting  about  the  bond  of  union  stretches,  as 
it  frequently  does,  the  power  of  extension  of  the  knee  may  be  retained 


Fig.  429. — Fracture  of  patella  before  operation. 
Episcopal  Hospital. 


Age  twenty-eight  years. 


(Fig.  428) ;  but  in  almost  all  cases  there  will  be  slight  limp,  and  some 
disability  in  going  up  stairs.    Operation  is  best  done  between  the  fifth 


FRACTURES  OF  THE  PATELLA 


411 


and  tenth  days  after  injury;  earlier  intervention  sometimes  is  followed 
by  infection,  and  infection  in  a  knee-joint  of  this  kind  usually  requires 
amputation,  and  may  result  in  the  patient's  death.  The  mortality 
of  operation  even  under  the  best  conditions  may  reach  4  per  cent. 
(E.  G.  Alexander,  1911).  The  strictest  aseptic  technique  is  impera- 
tive. A  semilunar  flap  is  turned  down  or  up,  exposing  the  seat  of 
fracture.  The  knee-joint  is  widely  opened,  and  clots  are  removed 
by  forceps  or  sponging  with  moist  gauze.  Any  fringes  of  the  quadri- 
ceps aponeurosis  turned  down  between  the  fragments  are  everted, 


Fig.  430. — Fracture  of  patella  after  suture  with  chromic  catgut.     Episcopal  Hospital. 

the  quadriceps  expansion  and  capsule  are  sutured  with  chromic  gut; 
and  the  skin  with  interrupted  silkworm  gut  (Figs.  429  and  430).  In 
most  cases  it  is  sufficient  to  suture  the  fibrous  tissues  alone,  without 
direct  suture  of  the  bone  (Blake,  Gibbon,  1904).  Few  surgeons  any 
more  employ  a  wire  suture.  If  all  oozing  has  been  checked,  and  the 
skin  is  not  sutured  too  tightly,  it  is  not  necessary  to  drain  the  wound; 
otherwise  a  small  drain  should  be  left  beneath  the  skin  for  forty-eight 
hours.  The  limb  is  dressed  on  a  posterior  splint,  which  may  be 
removed  in  a  few  days  and  the  limb  laid  on  a  pillow,  with  the  knee 


Ill' 


FRACTURES 


slightly  flexed.  Mosl  surgeons  now  recommend  beginning  very 
gentle  passive  motion  four  or  five  days  after  operation,  by  raising  the 
knee  a  few  inches  from  the  pillow  once  daily.  No  active  motion 
should  he  allowed  for  at  least  two  weeks,  and  not  then  unless  the 
bone  has  been  sutured  with  wire.  If  wire  has  been  used,  the  frag- 
ments depend  on  it  for  their  apposition  and  not  on  the  newly  formed 
callus.  The  patient  may  he  out  of  bed  in  the  third  or  fourth  week  but 
the  knee  should  be  supported  by  a  posterior  gypsum  splint,  or  light 
brace,  to  prevent  excessive  flexion  for  about  six  weeks  after  operation. 
With  non-absorbable  suture  the  patient  may  begin  to  walk  without 
support  in  three  or  four  weeks.  If  wire  has  been  used  it  may  require 
to  be  removed.     Kefracture  is  not  very  rare. 


Fig.  431. 


-Skiagraph  of  partial  separation  of  upper  epiphysis  of  tibia. 
(Schlatter's  disease.)     Episcopal  Hospital. 


Tibia. — These  fractures  frequently  are  caused  by  direct  violence, 
except  those  of  spiral  type  following  twists  of  the  foot,  and  those 
of  the  internal  malleolus  accompanying  fracture  of  the  lower  end  of 
the  fibula.  The  subcutaneous  position  of  the  tibia,  and  the  fact 
that  it  supports  the  main  weight  of  the  body,  render  it  much  more 


FRACTURES  OF  THE  TIBIA 


413 


liable  to  injury  than  the  fibula,  fractures  of  the  shaft  of  which  rarely 
occur  except  as  secondary  lesions  in  fractures  of  the  tibia.  The 
fractures  from  direct  violence  often  are  compound  or  comminuted. 

Fractures  of  the  upper  end  of  the  tibia  frequently  run  into  the  knee- 
joint  (Fig.  315),  and  synovitis  may  result;  as  the  fracture  may  be 
subperiosteal  or  impacted,  involve- 
ment of  the  knee-joint  with  pain  and 
tenderness  over  the  head  of  the  tibia, 
should  make  one  suspect  such  a  frac- 
ture. Complete  separation  of  the  upper 
epiphysis  of  the  tibia  is  rare,  but  "  start- 
ing of  the  epiphysis,"  sometimes  known 
as  Schlatter's  disease  (1903),  is  a  not 
infrequent  accompaniment  of  sprains 
of  the  knee  in  adolescents;  the  tibial 
tubercle,  which  forms  part  of  the 
epiphysis,  is  partially  loosened  by  the 
pull  of  the  tendo  patellae,  and  peri- 
osteal thickening  results  (Fig.  431). 
A  comparison  of  skiagraphs  of  both 
knees  is  necessary  for  diagnosis. 
Most  cases  resemble  "sprain-frac- 
tures" (p.  331),  but  in  some  the  tibial 
tubercle  is  broken  loose  and  is  pal- 
pable as  a  distinct  fragment.  Treat- 
ment consists  in  rest  until  acute 
symptoms  subside;  immobilization  of 
the  knee  should  be  continued  for 
several  weeks. 

Fractures  of  the  shaft  of  the  tibia  gen- 
erally are  oblique,  and  deformity  may 
be  great,  owing  to  the  pull  of  the  calf 
muscles  on  the  foot  which  causes 
shortening,  and  angular  projection 
forward  of  the  upper  fragment.  If 
this  is  pointed,  as  it  usually  is,  there 
is  danger  of  its  causing  a  slough  in  the 
skin  (Fig.  432).  There  also  is  a  ten- 
dency to  external  rotation  of  the  upper 
fragment  from  the  weight  of  the  thigh. 

Owing  to  the  deformity,  mobility,  and  crepitus,  diagnosis  is  easy. 
The  fibula  very  frequently  is  broken  also,  usually  at  a  higher  level, 
and  impaction  of  the  fibula  may  prevent  reduction  of  the  tibial 
fracture.  Treatment  consists  in  reduction  of  the  deformity  by 
extension,  counter-extension,  and  manipulation;  it  may  be  assisted 
by  placing  the  leg  in  Pott's  position  (1769) — lying  on  its  fibular 
side  with  the  knee  flexed  nearly  to  a  right  angle.  Where  posterior 
displacement    of    the    lower    fragment    is    very    persistent,   it    may 


Fig.  432. — Skiagraph  of  fracture  of 
both  bones  of  leg;  foot  displaced  back- 
ward by  gravity  and  contraction  of  calf 
muscles;  lower  pointed  end  of  upper 
tibial  fragment  protruding  subcu- 
taneously  on  front  of  leg.  Fracture 
of  fibula  comminuted  and  typically 
higher  than  that  of  tibia.  Episcopal 
Hospital. 


Ill 


FRACTURES 


be  advisable  to   divide  the  tendo  Achillis.     The  leg  may   be  put 

up  in  plaster  of  Paris  at  once,  in  cases  where  the  condition  of  the 
soft  parts  will  admit  of  this  procedure,  and  in  which  reduction  can 
be  surely  maintained  while  the  plaster  is  setting;  in  this  case  the 
dressing  must  extend  from  the  toes  to  above  the  knee,  and  it  is  very 


Fig.  433. — Long  fracture  box,  for  fracture  of  bones  of  leg.  Note  dry  dressing  over 
wound  of  compound  fracture  of  tibia  and  foot  bandaged  to  foot  piece.  Episcopal 
Hospital. 

important  to  keep  the  foot  at  a  right  angle  with  the  leg.  The  gypsum 
case  must  be  renewed  at  the  end  of  a  week  or  ten  days,  as  subsidence 
of  the  primary  swelling  will  have  rendered  it  loose  and  hence  useless 
in  keeping  the  fragments  in  good  position.  Better  than  the  circular 
case  is  the  use  of  moulded  splints  of  plaster  of  Paris;  these  are  made  by 


Fig.  434. — Long  fracture  box  for  fracture  of  bones  of  leg,  sides  raised  and  fastened 
around  leg.     Episcopal  Hospital. 

folding  the  wet  bandage  backward  and  forward  on  itself  until  splints 
of  the  desired  length  and  thickness  are  obtained,  which  are  applied 
to  the  leg  over  a  flannel  bandage,  and  moulded  around  the  limb  as 
the  plaster  sets.  If  one  such  splint  is  applied  along  the  back  of  the 
leg  and  foot,  and  one  along  each  side,  overlapping  beneath  the  sole, 


FRACTURES  OF  THE  FIBULA 


415 


very  excellent  fixation  is  secured  and  the  splints  may  be  removed  to 
permit  proper  care  of  the  soft  parts  once  or  twice  weekly.  In  cases 
where  the  primary  swelling  is  great,  with  bulla3,  ecchymoses,  etc.,  it  is 
better  to  postpone  the  application  of  a  plaster-of-Paris  dressing  for  a 
week  or  ten  days,  keeping  the  leg  meantime  in  a  fracture  box  (Figs.  433 
and  434),  securely  packed  into  a  pillow  which  fills  up  all  irregularities 
and  keeps  the  leg  straight ;  a  small  shot-bag  may  be  laid  over  the  pro- 
jecting fragment.  While  in  the  fracture  box  great  care  must  be  exer- 
cised to  protect  the  heel  and  malleoli  from  pressure  by  "floating"  the 
former  on  a  compress  placed  under  the  tendo  Achillis,  and  by  suitably 
padding  the  malleoli;  and  the  heel  should  be  kept  down  against  the 
foot-piece  of  the  fracture  box,  to  prevent  equinus  deformity.  Rotatory 
displacement  of  either  the  upper  or  lower  fragment  must  be  guarded 
against. 


Fig.  435.- 


-Skiagraph  of  Pott's  fracture  of  left  leg. 
Episcopal  Hospital. 


Age  forty-two  years. 


Fractures  of  the  Fibula. — Fracture  of  the  shaft  of  this  bone  is  rare, 
except  when  accompanied  by  fracture  of  the  tibia,  to  which  it  usually 
is  secondary.  In  such  cases  the  treatment  described  above  for  fracture 
of  the  tibia  is  to  be  employed.  Isolated  fracture  of  the  upper  part 
of  the  shaft  of  the  fibula  often  results  in  delayed  union  or  non-union, 


416 


FRACTURES 


as  it  is  very  difficult  to  secure  apposition  of  the  ends  of  fragments 
buried  in  such  a  mass  of  muscular  tissue.  Fracture  of  the  lower  fifth 
of  the  fibula  is  a  very  frequent  injury,  resulting  from  indirect  violence, 
the  foot,  as  a  rule,  being  turned  violently  outward  (abduction  frac- 
ture); as  the  astragalus  forces  the  external  malleolus  outward,  the 
tibio-fibular  ligaments  act  as  a  fulcrum,  so  that  the  fibula  is  bent  in 
against  the  tibia  above  the  attachment  of  these  ligaments,  and  finally 
breaks  at  this  point,  5  to  8  cm.  above  the  ankle-joint;  the  internal 
malleolus  often  is  avulsed  from  the  tibia,  at  the  same  time  (Fig.  435); 
and  to  this  combined  lesion  the  name  of  Pott's  Fracture  is  given,  it 


Fig.  436. — Skiagraph  of  fracture  of  lower  fifth  of  fibula,  internal  malleolus  and 
posterior  articular  surface  of  tibia,  with  posterior  dislocation  of  the  foot.  Episcopal 
Hospital. 


having  been  studied  carefully  and  graphically  described  by  Pott 
in  1771.  A  somewhat  similar  lesion  may  result  from  adduction  of 
the  foot,  but  then  usually  the  fracture  of  the  fibula  detaches  merely 
the  external  malleolus,  and  the  tibial  fracture  enters  the  ankle-joint. 
No  accurate  description  can  be  given  of  the  lines  of  fracture  in  these 
various  injuries,  as  they  vary  greatly  in  different  cases.  Other  lesions, 
which  may  or  may  not  be  present,  are  rupture  of  the  tibio-fibular 
ligament,  rupture  of  the  internal  lateral  ligament  of  the  ankle  without 
fracture  of  the  internal  malleolus,  fracture  of  the  posterior  border  of 
the  articulating  surface  of  the  tibia,  separation  of  the  lower  tibial 
epiphysis,  or  posterior  dislocation  of  the  ankle-joint  (Fig.  436). 


FRACTURES  OF  THE  FIBULA 


417 


Symptoms. — Symptoms  of  Pott's  fracture  are  a  well-marked  and 
characteristic  deformity,  consisting  in  abduction  of  the  foot,  and  marked 
prominence  of  the  internal  malleolus  or  of  the  lower  end  of  the  tibia 
when  the  malleolus  is  avulsed.  If  the 
posterior  articular  surface  of  the  tibia  is 
broken  also,  there  is  a  tendency  for  the 
foot  to  slide  backward,  causing  elongation 
of  the  heel  and  prominence  of  the  tibia 
anteriorly.  As  a  rule,  lateral  mobility 
is  marked,  and  crepitus  easily  detected. 
But  since  fracture  in  this  region  occa- 
sionally exists  without  displacement,  being 
subperiosteal  or  impacted,  the  surgeon 
always  should  treat  a  suspected  case  as 
one  of  fracture  until  this  can  be  disproved 
by  skiagraphy  or  otherwise. 

Treatment. — Accurate  reduction  is  im- 
perative if  a  good  result  is  to  be  obtained : 
imperfect  reduction  in  an  antero-posterior 
direction  will  limit  dorsal  flexion  of  the 
ankle,  and  imperfect  correction  of  the 
abduction  will  render  the  patient  liable  to 
develop  static  flat-foot,  and  will  cause  last- 
ing disability  in  locomotion   (Fig.    437). 

Sometimes  general  anesthesia  is  necessary  to  secure  reduction.  Grasp- 
ing the  heel  in  one  hand,  and  the  leg  in  the  other,  the  surgeon  brings 
the  foot  forward  until  the  astragalus  bears  its  normal  relation  to  the 
tibia,  and  then  adducts  the  foot,  so  as  to  replace  the  internal  malleolus 
and  overcome  the  internal  bowing  of  the  fibula.     Do  not  rotate  the  foot 


Fig.  437. — Deformity  follow- 
ing unreduced  Pott's  fracture  of 
left  foot,  two  months  after  in- 
jury.    Episcopal  Hospital. 


Fig.  438. — Dupuytren's  splint  for  Pott's  fracture.     Note  pads  along  tibial  surface 
of  leg,  allowing  inversion  of  foot.     Episcopal  Hospital. 


inward  on  the  long  axis  of  the  leg.  If  there  is  little  reaction  in  the  soft 
parts,  plaster-of-Paris  splints,  from  toes  to  knee,  may  be  applied  at  once, 
to  be  renewed  in  a  week  or  ten  days.  In  many  cases,  however,  it  is 
safer  to  dress  the  leg  temporarily  in  a  fracture  box,  with  a  pad  below 
the  external  malleolus  and  one  above  the  internal  malleolus  to  over- 
come eversion,  and  with  careful  support  to  the  heel,  keeping  this 
wTell  down  against  the  footboard  so  as  to  prevent  the  development 
of  the  pointed-toe  deformity;  or  the  leg  may  be  dressed  in  Pott's 
position  on  a  Dupuytren  splint  (1819)  (Fig.  438).  Weight  should 
27 


418 


FRACTURES 


not  be  borne  on  the  foot  for  at  least  eight  weeks.  In  many  cases, 
where  reduction  has  been  imperfect,  stiffness  and  edema  may  persist 
for  some  months,  and  may  require  massage,  passive  motion,  baking, 
or  eventually  operative  reduction  (Fig.  332)  for  their  relief. 


Frc  439. — Impacted  fracture  of  neck  of  right  astragalus.     Episcopal  Hospital. 


Fig.  44Q. — Skiagraph  of  fracture  of  calcaneum,  comminuted  and  impacted. 
Episcopal  Hospital, 


FRACTURES  OF  THE  FOOT 


419 


FRACTURES  OF  THE  FOOT. 

Fractures  of  the  Tarsus  usually  result  from  direct  violence  or 
falls  on  the  feet,  and  often  are  impacted.  Localized  tenderness 
following  severe  injury  is  the  most  valuable  symptom,  since  swelling 
of  the  soft  parts  may  obscure  deformity,  and  since  mobility  and 
crepitus  frequently  are  absent.  Corresponding  injuries  often  exist 
in  both  feet,  and  two  or  more  bones  often  are  fractured  in  the 
same  foot.  The  astragalus  most  frequently  is  broken  through  its 
neck  (Fig.  439;  see  also  p.  451).  Fractures  of  the  calcaheum  are 
more   frequent,   and    often   may   be  diagnosed    clinically    from   the 


Fig.  441. — Fracture  of  second,  third,  fourth,  and  fifth  metatarsal  bones.    Heavy 
stone  fell  on  foot.    Age  twenty-three  years.     Episcopal  Hospital. 

flattening  of  the  heel  and  prominence  of  the  calcaneum  below  the 
external  malleolus;  if  the  fracture  detaches  the  posterior  half  this 
may  be  considerably  displaced  upward  by  the  tendo  Achillis;  more 
often  there  is  a  general  crush  of  the  bone  (Fig.  440).  These  fractures 
are  best  treated  by  immobilization  in  good  position  in  plaster  of  Paris 
for  three  or  four  weeks;  but  weight-bearing  should  not  be  allowed  for 


420 


FRACTURES 


several  months.  Traumatic  flat-foot  should  be  Immediately  corrected 
by  moulding  the  foot  over  the  surgeon's  knee  or  a  sand  pillow,  as  the 
plaster  sets;  division  of  the  tendo  Achillis  may  be  necessary;  the  ever- 
sion  of  the  heel  should  be  corrected  also.  If  impaction  of  the  cal- 
caneum  with  deformity  cannot  be  overcome  without  incision,  it  will 
be  proper  to  do  osteotomy  of  the  heel  portion  so  as  to  restore  the 
normal  weight-bearing  surfaces.  This  has  been  done  by  Chutro  (1909) 
as  a  secondary  operation. 


Fig.  442. — Fracture  of  tuberosity  of  fifth  metatarsal  bone;  patient  had  been  treated 
for  "sprain  of  foot."     Age  twenty-three  years.     Episcopal  Hospital. 

Fractures  of  the  Metatarsus. — The  metatarsal  bones  usually  are 
fractured  by  direct  violence,  usually  two  or  three  at  once  (Figs.  441) . 
Deformity  is  slight,  but  disability  may  be  great.  Diagnosis  is  based 
on  persistent  localized  tenderness  usually  with  mobility,  and  some- 
times crepitus.  Fracture  of  the  base  of  the  fifth  metatarsal  bone  (Fig. 
442),  or  epiphyseal  separation  at  this  point,  which  is  a  less  frequent 
injury,  sometimes  occurs  from  direct  injury  in  stepping  on  the  outer 
side  of  the  foot. 

Fractures  of  the  Phalanges  are  rare,  even  from  direct  violence, 
and  then  usually  are  compound  and  require  amputation. 


CHAPTER   XIII. 
INJURIES  OF  JOINTS. 

SPRAINS   AND   CONTUSIONS. 

A  sprain  is  an  injury  to  the  ligamentous  structures  surrounding 
a  joint,  caused  by  a  wrench  or  a  twist;  there  may  be  a  subluxation 
or  actual  dislocation  of  the  bones  composing  the  joint,  spontaneously 
reduced.  Ross  and  Stewart  (1911)  maintain  that  every  sprain  is  a 
sprain-fracture  (p.  331),  the  ligament  giving  way  at  its  bony  attach- 
ment.1 Contusions  are  rarer  than  sprains,  and  are  due  to  direct  injury, 
the  blow  being  received  over  the  joint  or  being  transferred  to  it 
through  the  bones;  by  the  latter  mechanism  may  be  explained  frac- 
ture or  displacement  of  intra-articular  cartilages  (p.  448).  The  joints 
most  often  sprained  are  those  of  the  foot,  wrist,  shoulder  and  elbow. 

Symptoms. — The  symptoms  of  the  two  conditions  are  those  of 
inflammation  in  general,  with  perhaps  the  added  special  symptoms 
of  synovitis  (p.  503),  thecitis  (p.  310),  or  sprain-fracture  (p.  331). 
The  joint  assumes  that  position  in  which  tension  is  least,  the  ankle 
being  in  slight  plantar  flexion  and  adduction,  the  wrist  in  flexion, 
etc.  The  swelling,  heat,  redness,  etc.,  may  appear  in  a  few  moments, 
but  if  the  joint  is  well  supported  (e.  g.,  by  a  shoe),  and  its  use  is  per- 
sisted in,  they  may  not  manifest  themselves  until  after  support  is 
removed.  In  the  foot  the  subastragalar  joint  is  that  most  frequently 
sprained,  the  lesion  being  referred  to  popularly  as  "sprained  ankle'; 
the  normal  range  of  its  lateral  motion  is  suddenly  exceeded  either 
in  abduction  or  adduction,  with  laceration  or  complete  rupture  of 
the  internal  or  external  lateral  ligaments  at  the  ankle;  and  in  some 
cases  there  is  a  diastasis  of  the  tibio-fibular  joint.  There  commonly 
is  effusion  around  both  malleoli  (Fig.  443).  Distinction  from  fracture 
usually  is  possible  after  careful  examination,  by  excluding  abnormal 
mobility  or  localized  tenderness  of  the  bones  around  the  affected 
joint,  the  signs  in  sprains  pointing  to  the  soft  structures  as  the  seat 
of  lesion. 

Prognosis. — The  prognosis  is  good,  though  in  some  rheumatic 
patients  slight  disability  may  persist  for  months;  and  in  a  few  cases, 
especially  sprains  of  the  shoulder,  periarthritis  may  ensue  (p.  507). 

Treatment. — When  seen  early,  it  is  best  to  strap  the  ankle  with 
adhesive  plaster  (Fig.  444),  applying  a  firm  bandage  over  this.     In 

1  By  a  "strain"  usually  is  understood  a  sprain  of  slight  degree,  in  which  the 
tendinous  rather  than  the  ligamentous  structures  are  injured. 

(421) 


122 


INJURIES  OF  JOINTS 


mild  sprains,  limited  use  of  the  joint  may  be  allowed  when  thus  sup- 
ported, but  in  severe  cases  the  foot  should  be  elevated,  and  kept  at 
rest  for  several  days.  This  strapping  should  be  renewed  every  third 
or  fourth  day,  and  may  well  be  continued  until  function  of  the 
joint  can  be  resumed.  In  cases  not  seen  until  marked  swelling  has 
developed,  it  is  safer  to  treat  the  joint  with  anodyne  or  evaporating 
lotions  until  tenderness  and  swelling  begin  to  abate.  Sprains  of  the 
joints  of  the  upper  extremity  may  be  dressed  with  ichthyol  or 
belladonna  and  mercury  ointment,  and  the  limb  carried  in  a  sling. 
Absolute  immobilization  (plaster  of  Paris,  etc.)  rarely  is  advisable, 
as  tending  to  promote  stiffness  by  interference  with  the  circulation 
of  blood  and  lymph.  In  later  stages  much  benefit  is  derived  from 
alternate  hot  and  cold  douches,  massage,  and  gentle  passive  motion. 


Fig.  443. — Sprained  right  ankle  (recent 
accident).     Episcopal  Hospital. 


Fig.  444. — Adhesive  plaster  strapping  for 
ankle.     Episcopal  Hospital. 


WOUNDS    OF   JOINTS. 

Open  wounds  of  joints  usually  are  very  serious  lesions,  since  joints 
are  very  susceptible  to  infection.  They  may  be  incised,  lacerated, 
punctured,  etc.  Gunshot  wounds  of  joints  have  been  considered  in 
Chapter  VII. 

Diagnosis. — The  diagnosis  usually  can  be  made  by  noting  the 
situation  and  depth  of  the  wound,  or  by  observing  the  escape  of 
synovial  fluid,  and  the  increase  in  its  flow  on  manipulation  or  pressure 
of  the  joint;  under  no  circumstances  should  a  joint  wound  be  probed 
with  finger  or  instrument  until  all  proper  aseptic  preparations  have 
been  made. 

Prognosis. — The  prognosis  depends  on  the  joint  injured,  on  the 
nature  of  the  injury,  on  the  constitutional  state  of  the  patient,  and 


WOUNDS  OF  JOINTS  423 

On  the  treatment  employed.  Except  the  vertebral  joints,  the  knee 
is  the  most  dangerous  joint  in  the  body,  but  no  joint  wound  can  be 
regarded  as  trivial:  even  those  of  the  phalanges  may  require  ampu- 
tation, or  at  least  result  in  ankylosis.  Infection  is  the  great  danger, 
and  even  supposedly  aseptic  operations  occasionally  terminate 
fatally  when  the  knee  is  involved  (p.  411).  If  proper  treatment  is 
not  undertaken  promptly,  pyarthrosis  may  result,  followed  by  septi- 
cemia and  death,  in  spite  of  all  the  resources  of  surgery. 

Treatment.— If  seen  before  these  complications  have  arisen,  the 
wound  should  be  packed  with  sterile  gauze,  and  the  limb  surrounding 
it  prepared  as  for  an  aseptic  operation;  then  any  foreign  bodies 
remaining  in  the  wound  (cinders,  clothing,  glass,  needle,  etc.),  should 
be  extracted,  enlarging  the  wound  if  necessary,  and  evacuating 
blood  and  clots  from  the  interior  of  the  joint;  this  should  then  be 
gently  irrigated  (not  sponged)  with  warm  saline  solution,  and  the 
capsule  should  be  sutured  with  provision  for  drainage  of  the  overlying 
soft  parts.  The  joint  is  then  immobilized  by  splint  or  plaster  of 
Paris,  elevated,  and  surrounded  by  ice-bags.  In  the  case  of  large 
joints  weight-extension  should  be  applied.1  Constitutional  treat- 
ment (purge,  diuretic,  sedative)  should  not  be  neglected.  If  the 
joint  does  well,  as  shown  by  the  absence  of  pain  and  fever,  the  drain 
may  be  removed  on  the  second  day,  and  immobilization  continued  for 
one  or  two  weeks,  when  function  should  be  very  gradually  resumed. 
If  the  signs  of  infection  arise  (pain,  fever,  leukocytosis),  indicating 
the  development  of  septic  arthritis,  the  dressing  must  be  removed 
promptly,  and  drainage  instituted;  this  may  be  accomplished  by 
reopening  the  original  incision,  by  a  counter-opening,  or  by  numerous 
openings,  with  saline  irrigation  once  or  twice  daily,  or  in  desperate 
cases  by  wide  incision  of  the  joint  (in  the  knee  by  dividing  the  tendo 
patellae  and  acutely  flexing  the  knee — Dudley  Allen,  1906).  Instilla- 
tions of  Dakin's  solution  may  be  adopted,  as  described  at  p.  170;  or, 
as  advised  by  Churchman  (1918),  a  solution  of  gentian  violet  may 
be  used.  One  thorough  application  to  the  opened  joint  of  a  strong, 
hot  antiseptic  sometimes  will  check  the  infection,  usually  with  anky- 
losis as  a  result,  and,  as  already  mentioned  (p.  172),  Menciere  reports 
good  results  from  his  method  of  embalming.  But  if  septicemic 
symptoms  continue  in  spite  of  this  heroic  treatment,  the  surgeon 
has  only  two  resources  left:  these  are  excision  and  amputation.  In 
the  upper  extremity  the  former  usually  is  successful,  as  it  sometimes 
is  in  the  ankle-joint;  but  for  the  knee-joint  amputation  usually  is 
required,  and,  of  course,  should  be  resorted  to  in  the  case  of  other 
joints,  where  excision  has  failed.  Nor  should  these  radical  operations 
be  postponed  too  long,  as,  when  adopted  late  in  the  disease,  even  they 
may  fail  to  save  the  patient's  life. 

1  Willems'  plan  (p.  208)  of  treating  joint  wounds  and  cases  of  suppurative  arthritis 
by  active  mobilization,  has  not  been  generally  adopted. 


121  INJURIES  OF  JOINTS 

HEMARTHROSIS. 

Hemarthrosis  may  follow  subcutaneous  wounds  of  joints,  espe- 
cially gunshot;  it  also  is  more  frequent  than  is  commonly  supposed 
in  severe  sprains,  especially  of  the  knee.  The  symptoms  are  those  of 
acute  synovitis  (p.  504);  if  distention  is  marked  and  the  joint  very 
painful,  it  should  be  relieved  by  puncture  or  arthrotomy,  the  joint 
in  the  latter  instance  being  closed  without  drainage.  But  hemarthro- 
sis may  follow  slight  contusion  in  cases  of  hemophilia ,  and  in  such 
patients  may  be  a  very  serious  malady.  1  nder  no  circumstances 
should  such  a  joint  be  opened  for  exploration  or  drainage.  It  should 
be  put  at  rest,  ice  should  be  applied,  and  the  hemophilia  treated 
as  already  advised  (p.  259). 

DISLOCATIONS. 

Dislocation  or  luxation  of  a  joint  is  a  condition  in  which  the  articular 
surfaces  of  the  bones  forming  the  joint  are  no  longer  in  contact. 
Dislocations,  however,  may  be  complete  or  incomplete  (subluxation), 
the  articular  surfaces  in  the  latter  form  retaining  a  partial  contact 
with  each  other.  It  is  usual  to  classify  dislocations  as  traumatic, 
congenital,  and  spontaneous  or  pathological :  traumatic  dislocations  are 
those  resulting  from  the  application  of  force;  congenital  dislocations 
are  those  present  at  birth;  and  spontaneous  or  pathological  dislocations 
are  those  due  to  malformation  of  the  joint  surfaces  from  disease, 
or  to  laxness  of  the  periarticular  structures.  Dislocations  may  be 
simple,  compound,  or  complicated,  these  terms  having  the  same  sig- 
nificance as  when  applied  to  fractures;  they  may  be  recent  or  old, 
terms  of  relative  meaning,  and  which  sufficiently  explain  themselves; 
and  they  may  be  primitive,  when  the  displaced  bone  remains  where 
originally  placed  by  the  injury,  or  consecutive,  when  it  assumes  another 
position  owing  to  manipulations  by  bystanders,  the  surgeon,  etc. 
The  direction  of  the  dislocation  is  described  as  it  regards  the  distal 
bone  or  bones  forming  the  joint:  thus  posterior  dislocation  of  the 
elbow  means  that  the  forearm  (not  the  humerus)  is  displaced  back- 
ward; but  there  are  a  few  exceptions  to  this  rule,  which  will  be  noted 
later. 

In  the  present  chapter  only  traumatic  dislocations  are  considered, 
pathological  dislocations  being  discussed  with  diseases  of  the  joints, 
in  Chapter  XV,  and  congenital  dislocations  in  connection  with 
orthopedic  surgery,  in  Chapter  XVI. 

Causes. — As  in  the  case  of  fractures,  the  male  sex  and  active  adult 
life  act  as  predisposing  causes  of  luxation.  Certain  joints  are  dis- 
located much  more  commonly  than  others:  the  shoulder  contributes 
about  50  per  cent,  of  all  dislocations,  while  the  elbow,  the  clavicle, 
and  the  phalanges  contribute  only  about  5  to  10  per  cent,  each;  the 
hip,  ankle,  and  lower  jaw  contribute  from  3  to  5  per  cent,  each;  while 
the  wrist,  knee,  etc.,  are  very  rarely  dislocated. 


DISLOCATIONS  425 

Dislocations  are  caused  much  more  often  by  indirect  than  direct 
violence.  Usually  the  motion  of  the  joint  is  forced  beyond  its  normal 
limit,  the  distal  bone  impinging  against  a  fulcrum  formed  by  a  neigh- 
boring bone;  the  capsular  ligament  is  thus  ruptured  at  its  weakest 
point,  and  the  head  of  the  dislocated  bone  is  forced  through  this 
opening  either  by  continuation  of  the  original  force,  or  rarely  by 
secondary  muscular  contraction.  It  thus  happens  that  in  each 
joint  there  is  a  more  or  less  typical  primitive  dislocation,  because  the 
head  of  the  bone  habitually  emerges  at  the  weakest  part  of  the  capsule. 
If  direct  violence  is  the  cause,  the  capsule  and  accessory  band-like 
ligaments  are  widely  ruptured,  and  the  head  of  the  bone  may  pass 
almost  in  any  direction.  In  luxations  caused  by  leverage  (the  usual 
mechanism),  the  tear  in  the  capsule  always  is  sufficient  to  allow 
passage  of  the  head;  but  it  is  the  capsule  which  offers  the  main  obstacle 
to  reduction  since  by  secondary  displacement  of  the  luxated  bone, 
and  by  its  rotation  on  its  long  axis,  the  tear  in  the  capsule  becomes 
converted  into  a  slit  with  tense  margins.  But  though  this  slit-like 
opening  in  the  capsule  is  the  main  obstacle  to  reduction  further 
difficulty  is  afforded  by  muscular  contraction  and  resiliency,  which 
keep  the  bone  in  its  abnormal  position. 

Symptoms. — There  are  three  cardinal  symptoms  of  dislocation. 
(1)  Alteration  in  contour  of  the  affected  joint,  the  head  of  the  luxated 
bone  being  absent  from  its  socket  and  palpable  elsewhere.  (2)  Change 
in  length  of  the  affected  extremity — either  shortening  or  lengthening. 
(3)  Immobility  or  loss  of  normal  mobility.  In  many  dislocations 
there  also  is  evident  (4)  Change  in  the  axis  of  the  dislocated  bone. 
The  only  pathognomonic  sign,  however,  is  the  first,  absence  of  the 
head  of  the  dislocated  bone  from  its  socket  and  its  presence  elsewhere; 
and  even  here  confusion  may  arise,  if,  as  in  cases  of  fracture  of  the 
surgical  neck  of  the  scapula  (p.  367),  the  socket  as  well  as  the  head 
of  the  bone  is  displaced.  In  general,  however,  a  dislocation  may 
be  distinguished  from  a  fracture  near  a  joint,  by  the  facts  that  in  a 
fracture  there  is  abnormal  mobility  and  bony  crepitus;  and  that  when 
deformity  is  reduced  it  frequently  recurs;  whereas  in  dislocation  the 
normal  mobility  is  decreased  or  entirely  lost,  there  is  no  true  crep- 
itus, and  deformity  does  not  recur  when  the  dislocation  is  reduced. 
But  in  dislocation  caused  by  direct  violence  the  periarticular  struc- 
tures are  so  widely  disrupted  that  abnormal  mobility  may  exist,  and 
deformity  may  persistently  recur;  and  in  some  cases  there  may  be 
an  indistinct  moist  crepitus  due  to  contrition  of  the  luxated  bone 
with  the  side  of  the  socket;  moreover,  dislocation  and  fracture  may 
be  present  in  the  same  joint,  symptoms  of  both  conditions  being 
evident.  The  skiagraph  offers  a  controlling  test  by  which  almost 
always  it  is  possible  to  ascertain  the  true  lesion. 

Damage  to  periarticular  structures — nerves,  bloodvessels,  tendons — 
may  occur  in  dislocation,  as  in  fracture,  and  always  should  be  looked  for 
before  attempts  at  reduction  are  made.  Other  evidences  of  local  injury, 
such  as  pain,  swelling,ecchymosis,  etc.,  do  not  require  special  description. 


426  INJURIES  OF  JOINTS 

Changes  in  the  Joint  Surfaces  occur  within  a  comparatively  short 
time,  if  the  dislocation  is  not  reduced.  There  always  is  a  certain 
amount  of  blood  extravasated,  filling  the  capsule;  and  as  this  organizes 
the  socket  becomes  shallower,  the  capsular  tear  cicatrizes  and  con- 
tracts, the  surrounding  ligaments,  tendons,  bloodvessels,  and  nerves 
become  adherent  in  the  newly  formed  scar-tissue;  and  the  longer  the 
dislocation  remains  unreduced,  the  more  difficult  is  it  to  secure 
reposition.  In  the  course  of  time  the  luxated  bone  forms  for  itself 
a  new  socket,  which  will  furnish  a  certain  degree  of  solidity  and 
permit  a  moderate  amount  of  motion. 

Prognosis.  Prognosis  is  good  in  the  majority  of  cases  as  to  both 
lite  and  function.  Dislocations  very  rarely  are  fatal  injuries  unless 
compound  or  complicated.  Beyond  a  weakness  or  stiffness  lasting 
some  weeks  or  possibly  months,  most  patients  whose  dislocations 
have  been  promptly  and  skilfully  reduced  suffer  no  further  incon- 
venience; but  where  reduction  is  delayed,  or  where  unusual  force  has 
been  employed  in  securing  reduction,  a  certain  amount  of  disability 
may  persist  for  years  or  throughout  life. 

Treatment. — In  recent  dislocations  efforts  at  reduction  should  be 
made  at  once,  unless  the  patient  is  profoundly  shocked.  In  many  cases 
general  anesthesia  is  desirable  to  relieve  the  pain  and  abolish  muscular 
contraction,  which  is  aroused  anewT  at  every  attempt  to  manipulate  the 
limb.  Dislocations  are  reduced  by  two  methods,  which  may  be  classed, 
in  the  terminology  of  G.  G.  Davis  (1910),  as  the  direct  and  the  indirect: 
in  the  former  the  limb  is  first  placed  in  the  attitude  in  which  it  was 
when  the  dislocated  bone  burst  through  its  capsule,  and  the  head 
of  the  bone  is  then  pushed  or  pulled  directly  back  through  the  rent 
in  the  capsule  into  its  socket;  in  the  indirect  method  the  limb  is 
manipulated  in  such  a  way  as  to  bring  into  use  the  capsule  itself  and 
surrounding  ligaments  as  a  series  of  sliding  fulcra,  by  means  of  wThich 
the  dislocated  bone  is  levered  into  its  socket.  If  an  anesthetic  is 
administered,  completely  abolishing  muscular  contraction,  no  obstacle 
to  reduction  remains  except  the  joint  capsule,  and  it  depends  on  the 
skill,  patience,  and  dexterity  of  the  surgeon  to  insinuate  the  head 
of  the  dislocated  bone  through  the  capsular  opening  into  the  socket; 
for  this  to  be  accomplished,  no  force  is  required  beyond  what  may  be 
exerted  by  the  surgeon's  hands.  The  capsule  is  an  inelastic  structure, 
and  the  tear  through  which  the  dislocated  bone  emerges  always  is 
as  large  as  and  sometimes  larger  than  the  head  of  the  bone  itself. 
If  no  anesthetic  is  given,  it  may  be  necessary  to  supplement  the 
surgeon's  own  power  by  weight-extension,  gravity,  etc.,  especially  if 
the  patient  has  a  highly  developed  muscular  system;  in  other  cases  it 
will  be  easy  to  reduce  the  luxation  by  taking  the  muscles  by  surprise, 
as  it  wrere,  and  replacing  the  bone  while  the  patient  thinks  a  mere 
preliminary  examination  is  being  conducted. 

All  efforts  at  reduction  by  conservative  means  having  failed,  the 
surgeon  may  resort  to  arthrotomy,  by  which  he  will  be  enabled  to 
enlarge  the  rent  in  the  capsule,  and  to  displace  tendons,  ligaments, 


DISLOCATIONS  427 

etc.,  caught  around  the  head  of  the  bone,  this  latter  condition  being 
almost  the  sole  factor  which  renders  a  recent  dislocation  really  irre- 
ducible. Usually  operation  is  not  undertaken  until  several  days 
after  the  injury,  different  surgeons  having  meantime  maltreated  the 
limb  by  applying  excessive  force  in  attempts  at  reduction;  this  renders 
the  operation  more  difficult  and  less  likely  to  be  successful  than  if 
done  before  such  unskilful  attempts  have  been  made. 

Reduction  having  been  secured,  the  joint  should  be  kept  at  rest, 
in  such  a  position  as  to  prevent  re-dislocation,  for  a  period  of  ten  days 
or  two  weeks;  and  for  several  weeks  longer  all  violent  motions,  or 
even  gentle  motions  of  wide  range,  should  be  prohibited.  Massage 
often  is  beneficial. 

Compound  Dislocations  are  to  be  treated  according  to  the  principles 
inculcated  when  speaking  of  wounds  of  joints.  Owing  to  the  great 
force  necessary  for  their  production,  and  the  wide  laceration  of  the 
soft  parts,  reduction  usually  is  easy.  They  are  most  frequent  at  the 
elbow  and  ankle. 

Complicated  Dislocations. — Fractures  complicating  dislocations  are 
discussed  at  p.  347.  Rupture  of  the  main  vessels  at  a  dislocated  joint 
is  to  be  treated  as  a  wound  of  the  vessels  under  other  circumstances. 
Lesions  of  nerves  accompanying  dislocation  should  be  treated  con- 
servatively until  no  further  improvement  can  be  expected;  unless, 
of  course,  it  is  evident  that  complete  rupture  of  a  nerve  trunk  has 
occurred,  when  primary  suture  should  be  done. 

Old  Dislocations. — Some  dislocations  become  "old"  much  sooner 
than  others,  and  it  is  not  always  advisable  to  attempt  reduction. 
Sir  Astley  Cooper  (1822)  set  three  months  as  the  limit  for  the  shoulder, 
and  eight  weeks  for  the  hip,  not  because  reduction  could  not  sometimes 
be  obtained  after  the  lapse  of  a  longer  time,  but  because  it  was  secured 
at  the  expense  of  such  damage  to  the  soft  parts  that  the  remedy  was 
worse  than  the  disease.  The  first  question,  therefore,  which  arises 
in  a  case  of  old  dislocation,  is  whether  or  not  reduction  shall  be  at- 
tempted. And  it  may  be  answered  affirmatively  in  almost  every 
case,  since  even  though  the  attempt  prove  a  failure  a  skilful  surgeon 
by  judicious  and  gentle  manipulation  of  a  dislocated  joint  almost 
invariably  will  be  able  to  improve  the  function  of  the  part.  But 
as  to  whether  attempts  at  reduction  will  be  .successful,  it  is  much 
more  difficult  to  formulate  an  answer,  much  depending  on  the  duration 
of  the  condition,  the  age  of  the  patient,  and  the  joint  involved.  At 
the  present  day  mere  duration  of  the  condition  is  very  little  con- 
sidered, since  should  reduction  fail  by  manipulation,  it  may  succeed 
by  arthrotomy;  and  as  a  last  resort  the  surgeon  may  have  recourse 
to  excision  of  the  joint  or  of  the  head  of  the  dislocated  bone,  an 
operation  which  generally  will  improve  function,  though  not  restoring 
it  to  normal.  But  the  age  of  the  patient  is  an  important  consideration; 
in  the  very  old,  while  manipulation  might  succeed  in  securing  reduc- 
tion more  easily  than  in  those  of  active  middle  life,  yet  the  risk  of 
producing  fracture  would  be  so  great,  and  the  advantages  to  be  gained 


1JS  INJURIES  OF  JOINTS 

so  temporary,  that  as  a  rule  it  is  better  to  leave  the  joint  alone 
unless  the  condition  is  very  disabling.  The  hip-joint  is  that  in  which 
dislocation  becomes  irreducible  most  rapidly;  the  knee  probably  is 
second,  the  elbow  third,  and  the  shoulder  fourth.  But  in  the  hip 
and  the  shoulder,  especially  the  latter,  if  massage  and  passive  motion 
are  persisted  in  long  enough,  a  fair  range  of  motion  may  be  secured 
without  reduction.  In  the  elbow  arthrotomy  usually  will  be  successful 
in  securing  reduction  and  a  useful  limb;  while  in  the  knee  excision 
may  be  required. 

Recurrent  Dislocations  are  commonest  at  the  shoulder,  and  may 
require  pleating  of  the  capsule  by  suture  as  practised  by  T.  T.  Thomas 
(1909).     He  employs  an  axillary  incision. 

SPECIAL  DISLOCATIONS. 

Mandible. — Usually  this  is  produced  through  muscular  action  in 
yawning,  though  it  may  follow  a  downward  blow  on  the  chin.  The 
luxation  may  be  unilateral  or  bilateral,  and  the  displacement  nearly 
invariably  occurs  foricard:  the  condyle  ruptures  the  weak  anterior 
portion  of  the  capsular  ligament,  rides  forward  on  the  eminentia 
articularis  beyond  its  normal  limit,  and  is  held  there  by  spasmodic 
contraction  of  the  external  pterygoid  muscle,  assisted  by  the  tem- 
poral and  masseter.  The  mouth  remains  open,  and  if  only  one  side 
of  the  jawr  is  dislocated,  the  chin  is  displaced  to  the  other  side. 

Treatment. — Reduction  is  secured  by  forcibly  opening  the  mouth 
further,  at  the  same  time  depressing  the  body  of  the  bone  by  placing 
the  thumbs  (carefully  guarded  by  adhesive  plaster,  gauze,  etc.) 
over  the  back  molar  teeth,  and  finally  raising  the  chin  by  the  dis- 
engaged fingers.  Recurrence,  not  very  rare,  should  be  prevented  by 
application  of  a  bandage,  such  as  Barton's,  for  about  ten  days. 

Subluxation  of  the  jaw  is  a  term  employed  by  Sir  Astley  Cooper 
(1822)  to  describe  a  frequently  repeated,  usually  self-reduced,  uni- 
lateral displacement  of  the  mandibular  condyle,  due  to  looseness 
of  the  intra-articular  cartilage.  Probably  it  is  more  often  the  carti- 
lage that  is  displaced  than  the  condyle;  the  cartilage  has  the  external 
pterygoid  muscle  attached  to  it  anteriorly,  and  the  displacement  is 
forward.  In  case  the  displacement  is  not  self-reduced,  Pringle  (1919) 
advises  its  replacement  "by  keeping  up  hard  pressure  at  the  back  of 
the  condyle  with  the  mouth  open,  and  slowly  closing  the  jaw."  In 
mild  cases  it  constitutes  the  condition  known  as  "clacking  jaw;" 
aside  from  the  noise  of  the  cartilage  slipping  around,  which  is  audible 
to  the  patient  and  occasionally  to  those  close  to  him,  little  inconven- 
ience is  experienced.  Treatment,  when  any  is  required,  consists  in 
administration  of  tonics,  use  of  counter-irritants,  injection  of  formalin 
or  alcohol,  and,  as  a  last  resort,  excision  of  the  cartilage. 

Central  dislocation  of  the  jaw  is  a  very  rare  lesion,  usually  fatal, 
in  wmich  the  condyle  is  driven  through  the  base  of  the  skull. 

Vertebrae.— See  Chapter  XVII. 


DISLOCATION  OF  THE  CLAVICLE 


429 


Clavicle. — This  bone  may  be  dislocated  at  either  end,  dislocation 
at  the  acromio-clavicular  joint  forming  an  exception  to  the  rule  for 
nomenclature  of  luxations  formulated  at  p.  424. 


Fig.  445.  —  Mechanism  of  dislocation  of 
right  sterno-clavicular  joint.    See  text. 


Fig.  446. — Mechanism  of  dislocation  of 
right  acromio-clavicular  joint.    See  text. 


Dislocation  of  the  Sterno-clavicular  Joint. — The  clavicle  usually 
is  displaced  upward  and  forward.  The  injury  is  produced  by  falls 
or  blows  causing  sudden  depression  of  the  shoulder,  the  clavicle 
coming  into  contact  with  the  first  rib  close  to  the  sternum ;  as  the 
costo-clavicular  ligament  prevents 
the  clavicle  from  giving  at  the 
point  of  attachment,  the  inner  ex- 
tremity is  pried  out  of  its  socket 
over  the  first  rib  as  a  fulcrum  (G. 
G.  Davis,  1910)  (Fig.  445).  The 
intra-articular  cartilage  usually  is 
displaced  with  the  clavicle.  Symp- 
toms are  self-evident  (Fig.  417), 
and  reduction  is  easy  to  secure  by 
raising  the  outer  end  of  the  clavi- 
cle and  drawing  the  shoulder  back- 
ward; but  it  is  difficult  to  prevent 
recurrence.  The  arm  may  be  carried 
in  a  sling,  and  a  firm  spica  of  the 
shoulder  applied  (Fig.  89)  with  a 
pad  over  the  inner  end  of  the  clavi- 
cle. Some  deformity  almost  always 
persists,  but  function  is  good.  In 
some  cases  the  joint  may  be  opened 
and    the  bones    sutured  in    place. 

Backward  dislocation  at  the  sternal  end  is  rare,  and  may  be  accom- 
panied by  dyspnea,  dysphagia,  etc.  In  the  only  patient  I  have  seen, 
under  the  care  of  Dr.  F.  T.  Stewart  in  the  Pennsylvania  Hospital, 


Fig.  447. — Recurrent  dislocation  of 
sternal  end  of  right  clavicle.  Ortho- 
paedic Hospital. 


430  INJURIES  OF  JOINTS 

the  only  pressure  effects  were  due  to  compression  of  the  subclavian 
vein,  and  were  promptly  relieved  by  drawing  the  shoulder  back- 
ward. A  posterior  figure-of-eight  bandage  (Fig.  92)  makes  a  good 
dressing.  Downward  dislocation  at  this  joint  may  occur  when  frac- 
ture of  the  first  rib  coexists;  it  is  a  serious  injury,  the  result  of 
great  direct  violence. 

Dislocation  of  the  Acromioclavicular  Joint  usually  results  from 
depression  and  inward  rotation  of  the  scapula,  from  falls  or  blows 
on  the  point  of  the  shoulder.  This  carries  the  base  of  the  coracoid  up 
against  the  clavicle,  and  as  the  clavicle  is  fastened  to  this  by  the  strong 
coraco-clavicular  ligaments,  the  only  motion  possible  is  an  upward  dis- 
placement of  the  acromial  end  of  the  clavicle,  the  coracoid  acting  as  a 
fulcrum  (G.  G.  Davis,  1910)  (Fig.  446).  The  deformity  is  self-evident, 
and  like  that  at  the  inner  end  is  easy  to  overcome  but  difficult  to 
keep  reduced.  However,  by  fixing  the  upper  extremity  in  the  Velpeau 
position,  with  the  dressing  advised  for  fracture  of  the  clavicle,  the 
turns  of  the  bandage  over  the  shoulder  and  under  the  flexed  elbow 
(Fig.  356)  will  keep  the  bones  in  place  as  long  as  the  bandages  remain 
firm.  This  dressing  should  be  continued  two  weeks  or  more.  As  in 
luxation  of  the  sternal  end,  suture  may  be  adopted  for  persistent 
deformity  if  it  entails  disability,  which  is  rare.  Downward  and  back- 
ward  dislocations  occur,  but  are  very  unusual. 

Scapula. — The  only  dislocation  of  this  bone  recognized  by  system- 
atic writers  consists  in  displacement  of  its  lower  vertebral  border 
from  beneath  the  fibers  of  the  latissimus  dorsi,  usually  from  indirect 
violence  or  muscular  strain.  If  firm  bandaging  is  not  sufficient,  the 
muscle  may  be  re-attached  by  suture.  The  deformity  seen  in  some 
cases  of  phthisis  (winged  scapula),  and  after  paralysis  of  the  serratus 
magnus  muscle,  closely  simulates  this  "dislocation"  of  the  scapula. 

Shoulder. — Dislocations  of  the  head  of  the  humerus  may  occur 
anterior  or  posterior  to  the  glenoid  cavity,  the  posterior  variety  being 
exceedingly  rare.  There  are  many  reasons  for  this:  the  shoulder 
usually  is  dislocated  by  injuries  which  produce  extreme  abduction 
of  the  arm,  and  as  the  force  generally  acts  from  the  front,  the  arm 
is  carried  backward  as  it  is  abducted.  As  the  glenoid  process  looks 
more  forward  than  outward,  such  a  motion  throws  most  strain  on 
the  anterior  part  of  the  capsule  of  the  shoulder-joint;  and  if  while 
the  arm  is  abducted  slightly  posteriorly  an  inward  thrust  or  a  pull 
by  the  axillary  muscles  is  added,  this  portion  of  the  capsule  will  be 
ruptured;  or  if  abduction  continues  until  the  humerus  strikes  against 
the  acromion,  after  all  possible  leeway  has  been  gained  by  rotation 
of  the  scapula,  then  the  head  of  the  humerus  will  be  pried  out  of 
the  capsule  over  the  acromion  as  a  fulcrum.  The  capsule  is  torn 
loose  from  the  glenoid,  from  the  base  of  the  coracoid  above  to  the 
attachment  of  the  triceps  below;  and  through  this  rent,  which  may 
be  increased  by  rotation  of  the  humerus,  the  humeral  head  emerges 
in  the  axilla,  in  front  of  the  triceps.  If  the  arm  remains  in  the  position 
of  extreme  abduction,  which  is  extremely  rare,  the  condition  is  de- 


DISLOCATION  OF  THE  SHOULDER 


431 


scribed  as  luxatio  erecta;  usually,  by  the  force  of  gravity  or  the  assist- 
ance of  bystanders,  the  patient's  arm  is  brought  down  to  his  side, 
and  the  head  of  the  bone  passes  beneath  the  coracoid  [sub-coracoid 
dislocation)  where  it  usually  remains,  or  may  be  displaced  further 
inward,  into  a  subclavicular  position.  All  these  (axillary,  subcoracoid, 
subclavicular)  are  varieties  of  anterior  dislocations.  Posterior  dis- 
locations, unless  congenital,  usually  result  only  from  extreme  direct 
violence,  tearing  loose  ligaments  and  tendons  on  all  sides;  or  some- 
times by  inward  rotation  and  adduction,  with  a  backward  thrust,  the 
lesser  tuberosity  impinging  on  the  coracoid  process.  Sometimes 
they  are  consecutive  displacements,  the  primitive  dislocation  having 
been  anterior.  The  head  of  the  bone  may  be  displaced  only  slightly 
backward  (subacromial),  or  so  far  as  to  merit  the  term  subspinous. 


Fig.  448. — Recent  subcoracoid  luxation  of  left  humerus,  patient  aged  seventy  years. 
Reduced  without  anesthetic  by  Kocher's  method.     Episcopal  Hospital. 

In  anterior  dislocations  the  subscapularis  muscle,  stretched  over 
the  capsule  at  the  point  of  rupture,  may  itself  be  perforated  by  the 
head  of  the  humerus,  though  usually  this  emerges  below  the  sub- 
scapularis. The  circumflex  or  musculospiral  nerve  may  be  stretched 
or  lacerated,  though  recent  observations  seem  to  show  that  the 
lesions  if  permanent  more  often  are  in  the  spinal  roots  forming  the 
outer  cord  of  the  brachial  plexus  (p.  316).1  In  most  cases  there  is 
tingling  and  numbness  in  the  fingers,  and  some  distention  of  the 
veins,  from  pressure  on  the  axillary  vessels. 

Symptoms. — The  appearance  of  patients  with  dislocation  of  the 
shoulder  is  characteristic  (Fig.  448) :  the  arm  hangs  a  little  away  from 
the  side,  there  is  a  hollow  under  the  acromion,  and  the  head  of  the 
bone  may  be  seen  beneath  the  coracoid.    As  the  head  of  the  humerus 

1  Delbet  and  Cauchoix  (1910)  collected  36  cases  of  paralyses  complicating  dis- 
locations of  the  shoulder:  25  of  these  were  terminal  paralyses,  and  were  produced 
by  the  dislocation  itself;  the  remaining  11  lesions  all  were  radicular  and  were  due 
not  to  the  dislocation  but  to  the  cause  which  produced  the  dislocation. 


432 


INJURIES  OF  JOINTS 


has  been  displaced  from  its  pedestal,  and  has  been  drawn  against  the 
side  of  the  thorax,  and  as  the  thoracic  cage  is  convex,  it  is  impossible 
to  bring  the  elbow  against  the  side  of  the  chest  at  the  same  time  that 
the  hand  is  placed  on  the  uninjured  shoulder  (Dugas's  sign,  1856). 
In  recent  cases,  and  in  not  very  obese  patients,  the  diagnosis  is 
easy;  but  when  swelling  has  occurred,  and  after  much  manipulation 
by  others,  it  may  be  quite  difficult;  and  it  is  in  such  circumstances 
that  Dugas's  sign  and  the  x-ray  (Fig.  449)  become  valuable  aids. 


Fig.  449. — Subcoracoid  dislocation  of  humerus.     Episcopal  Hospital. 

In  posterior  dislocation  the  head  of  the  bone  is  palpable  beneath 
the  infraspinous  muscles,  the  glenoid  cavity  is  empty,  the  coracoid 
process  is  unusually  prominent,  and  the  other  usual  symptoms  of 
dislocation   are  present. 

Treatment. — The  indirect  method  of  reduction,  or  that  by  manipu- 
lation, is  preferable.  This  was  proposed  in  1858  by  H.  H.  Smith, 
Professor  of  Surgery  in  the  University  of  Pennsylvania,  and  later 
(1863)  systematized  by  him;  he  thought  muscular  contraction, 
especially  that  of  the  supraspinatus,  as  taught  by  Sir  Astley  Cooper, 
was   the   main   obstacle  to  reduction.      Kocher,   later   Professor   of 


DISLOCATION  OF  THE  SHOULDER  433 

Surgery  in  Bern,  in  1870  adopted  a  similar  method,  founded  on  that 
of  Schinzinger  (1862);  he  recognized  the  capsule  as  the  chief  obstacle 
to  and  best  aid  in  securing  reduction. 

H.  H.  Smith's  Method  of  Reduction. — The  patient  being  on  his 
back,  (1)  elevate  the  arm  in  the  sagittal  plane  until  it  is  nearly  vertical 
(step  two,  of  Kocher's  method) ;  this  relaxes  the  supraspinatus  muscle, 
as  well  as  the  coraco-brachialis  and  short  head  of  the  biceps,  per- 
mitting step  two  to  be  more  effectually  executed.  (2)  Keeping  the 
arm  vertical,  and  using  the  bent  forearm  as  a  lever,  rotate  the  humerus 
outward;  by  doing  this  the  untorn  posterior  portion  of  the  capsule 
is  wound  around  the  head  and  upper  part  of  the  neck  of  the  humerus 
(Farabeuf,  1885),  and  acting  as  a  sliding  fulcrum  draws  the  head 
of  the  bone  away  from  the  chest,  until  the  subscapulars  becomes 
tense  and  resists  further  rotation.  (3)  Then  slowly  adduct  the  arm 
across  the  chest,  still  maintaining  outward  rotation  of  the  humerus; 
when  the  elbow  touches  the  chest,  the  hand  is  brought  down  to  the 
opposite  shoulder,  and  the  bone  usually  will  be  replaced. 

T.  Kocher's  Method  of  Reduction. — (1)  Bring  the  elbow  against  the 
chest,  and  rotate  the  humerus  outward  as  far  as  it  will  go,  using  the 
bent  forearm  as  a  lever  (Fig.  450) ;  do  not  push  this  outward  rotation 
too  far,  and  do  it  with  a  very  gradual  and  gentle  but  persistent  motion; 
force  is  very  liable  to  fracture  the  humerus;  Kocher  himself  broke 
it  three  times  in  reducing  twenty-eight  luxations.  During  this  out- 
ward rotation  of  the  humerus  the  same  phenomena  occur  as  during 
step  two  of  Smith's  method,  but  the  lesser  tuberosity  may  catch  under 
the  tense  coraco-brachialis,  and  this  is  one  cause  of  the  frequency 
of  fracture  of  the  humerus  (G.  G.  Davis,  1910).  (2)  Raise  the  elbow 
in  the  sagittal  plane,  or  in  slight  adduction,  until  the  arm  is  as  nearly 
vertical  as  possible  (Fig.  451);  this  relaxes  the  anterior  border  of  the 
rent  in  the  capsule  (coraco-humeral  ligament)  and  the  coraco- 
brachialis  and  short  head  of  the  biceps,  which  hinder  the  ascent  of 
the  head  on  to  the  glenoid  process.  (3)  Rotate  the  arm  inward, 
using  the  bent  forearm  as  a  lever,  until  the  hand  touches  the  sound 
shoulder,  then  quickly  bring  the  elbow  to  the  side  of  the  chest  (Fig. 
452).  This  last  step  slides  the  head  of  the  bone  back  through  the 
rent  in  the  capsule,  whose  posterior  untorn  part  is  now  on  the  inner 
instead  of  the  outer  side  of  the  humerus,  and  again  acts  as  a  fulcrum 
to  lever  the  head  upward;  but  reduction  often  is  accomplished  at  the 
conclusion  of  the  second  step. 

Of  these  two  methods,  Smith's  undoubtedly  is  the  better,  though 
neither  of  them  rests  on  the  anatomo-pathological  basis  which  was 
erected  for  them  by  their  authors;  Smith  thought  the  muscles  the 
all  important  factor,  while  Kocher  thought  success  depended  on  the 
gleno-humeral  ligament,  which  was  shown  by  Farabeuf  to  be  of  no 
consequence.  The  great  advantage  of  these  methods  of  manipulation 
is  that  an  anesthetic  usually  is  not  required  in  recent  cases,  and  that 
they  can  be  applied  by  the  surgeon  without  other  assistance  than  the 
inertia  of  the  patient's  body.  They  depend  for  their  efficiency, 
28 


i:u 


INJURIES  OF  JOINTS 


however,  on  the  untom  >tate  of  the  posterior  part  of  the  capsule;  if 
this  portion  also  is  torn,  the  head  of  the  humerus  will  not  be  pulled 


FlG.  450. — Kochcr's  method  of  reducing  dislocation  of  shoulder,  first  step:  outward 
rotation.    Episcopal  Hospital. 


Fig.  451. — Reduction  of  dislocation  of  shoulder  by  Kocher's  method;  second  step: 
elevation  of  arm  in  sagittal  plane.     Episcopal  Hospital. 


Fig.  452. — Reduction  of  dislocation  of  shoulder  by  Kocher's  method;  third  step: 
hand  brought  to  shoulder  and  elbow  to  chest.     Episcopal  Hospital. 


away  from  the  chest  during  outward  rotation,  but  will  rotate  in  situ. 
Under  such  circumstances  the  rent  in  the  capsule  will  be  so  large 


DISLOCATION  OF  THE  SHOULDER  435 

that  no  difficulty  should  be  experienced  in  replacing  the  head  of  the 
bone  by  direct  pressure,  after  it  has  been  drawn  away  from  the  chest 
by  extension  and  counter-extension. 

The  methods  of  direct  reposition  are  many;  all  of  them  depend 
first  on  bringing  the  head  of  the  bone  opposite  the  tear  in  the  capsule, 
and  consequently  aivay  from  the  chest  wall  and  out  to  the  neighborhood 
of  the  glenoid  -process;  and  then  on  pushing  or  pulling  it  into  its  socket. 
The  head  can  be  brought  away  from  the  side  of  the  thorax  only  by 
eliminating  or  overcoming  the  muscular  contraction  which  holds 
it  there,  either  by  continuous  traction  or  a  general  anesthetic. 

1.  Sir  Astley  Coopers  Method  (1822):  With  the  patient  supine, 
place  the  heel  of  the  unbooted  foot  in  the  patient's  axilla,  against 
the  chest,  and  make  traction  downward  and  slightly  outward  on  the 
upper  extremity;  the  traction  pulls  the  head  free  from  the  coracoid, 
and  by  slight  leverage  over  the  foot,  the  head  is  pushed  directly 
into  its  socket.  A  little  rotation  in  and  out  may  assist.  This  is  a 
very  efficient  method,  really  combining  all  others  (extension  and 
counter-extension,  leverage,  and  manipulation),  but  it  is  very  painful 
and  usually  requires  anesthesia;  and  the  inexpert  or  brutal  may 
cause  serious  injury  to  the  axillary  tissues. 

2.  Stimson's  Method  (1900):  The  patient  is  laid  on  a  canvas  sling, 
with  the  dislocated  extremity  passed  through  a  hole  in  the  canvas 
and  hanging  free  of  the  floor;  a  weight  of  about  ten  pounds  is  attached 
to  the  wrist  or  elbow.  The  limb  is  kept  thus  in  abduction,  and  in 
a  few  minutes  (never  more  than  six,  Stimson)  reduction  of  the  dis- 
location takes  place  quietly  and  without  pain.  No  anesthetic  is 
required,  as  the  weight  tires  out  the  muscles  which  hold  the  head 
of  the  humerus  against  the  chest;  and  as  soon  as  it  is  drawn  out  to 
the  region  of  the  glenoid  process,  it  slips  into  its  socket  spontaneously. 

3.  Malgaigne's  Method  (1855)  is  the  reverse  of  Stimson's:  The 
patient  lies  on  the  sound  side  on  the  floor,  and  a  robust  assistant 
pulls  vertically  upward  on  the  dislocated  extremity,  till  the  shoulders 
just  clear  the  floor,  and  maintains  this  traction  till  the  patient's 
axillary  muscles  are  exhausted;  the  surgeon  then  pushes  the  head 
of  the  bone  into  place. 

Many  other  modifications  of  this  principle  have  been  devised,  and 
constantly  are  being  reinvented  by  ingenious  surgeons. 

In  posterior  dislocations  upon  the  cadaver  I  have  succeeded  in 
securing  reduction  by  reversing  the  manipulations  of  Kocher's  and 
Smith's  methods;  but  usually  in  life  the  capsule  is  so  widely  torn 
that  the  luxation  is  easily  reduced  by  direct  pressure  forward  or  very 
slight  manipulation. 

After  reduction,  the  arm  is  dressed  in  the  Velpeau  position  and 
guarded  use  may  be  permitted  after  two  weeks.  It  is  possible  that 
if  reduction  were  accomplished  more  often  by  manipulation  and  less 
often  by  brute  force  less  disability  as  the  result  of  periarthritis  would 
follow  this  [injury.  Yvert  (1911)  studied  the  statistics  of  various 
surgeons  and  found  that  Go  per  cent,  of  the  patients  had  persistent 


436 


I.X.Ilh'll'S  OF  JOINTS 


disability,  22  per  cent,  had  fairly  satisfactory  function,  and  only 
13  per  cent,  had  excellent  results. 

Elbow. — The  typical  dislocation  at  the  elbow  consists  in  backward 
displacement  of  both  bones  of  the  forearm;  anterior  dislocation  of  both 
bones  is  rare;  and  lateral  dislocations  usually  are  incomplete  and  often 
accompanied  by  fracture  of  one  or  other  of  the  humeral  condyles. 

Posterior  Dislocation. — Posterior  dislocation  is  most  frequent  from 
fifteen  to  thirty  years  of  age,  and  results  almost  invariably  from  a 
fall  on  the  out-stretched  hand  causing  hyperextension  of  the  elbow, 
the  olecranon  acting  as  a  fulcrum  and  prying  the  bones  apart;  the 
anterior  capsule  is  ruptured,  and  the  internal  lateral  ligament  more 
or  less  lacerated,  and  detachment  of  the  epitrochlea  of  the  humerus 
often  occurs.  Fracture  of  the  olecranon  by  compression  sometimes 
is  seen,  and  occasionally  the  coronoid  process  is  broken  off. 


Fig.  453. — Old  unreduced  posterior  dislocation  of  elbow,  with  evidences  of  hypertrophic 
arthritis.     Episcopal  Hospital. 

Symptoms.— The  deformity  usually  is  quite  apparent.  The  fore- 
arm, usually  pronated,  is  carried  at  an  obtuse  angle  with  the  arm, 
and  motion  is  painful  and  restricted.  The  radius  and  ulna  may  be 
displaced  directly  backward,  but  often  there  is  also  slight  lateral 
displacement.  The  olecranon  is  found  displaced  posteriorly  and 
upward  in  relation  to  the  condyles,  and  the  greater  sigmoid  fossa 
of  the  ulna  often  can  be  felt  between  the  tense  triceps  and  posterior 
surface  of  the  humerus  (Fig.  453).  The  head  of  the  radius  is  absent 
from  its  normal  place  just  in  front  of  the  external  condyle  and  can 


DISLOCATION  OF   THE  ELBOW  437 

be  felt  posteriorly.  Anteriorly  the  lower  extremity  of  the  humerus  fills 
the  flexure  of  the  elbow.  The  diagnosis  from  supracondylar  fracture, 
referred  to  at  p.  37(>,  should  present  no  difficulties,  and  in  case  of 
doubt,  the  lesion  is  much  more  likely  to  be  a  fracture  than  a  dis- 
location. If  the  lesion  is  recognized,  and  the  luxation  promptly 
reduced,  recovery  is  rapid,  and  in  most  cases  nearly  perfect  function 
is  secured. 

Treatment. — In  recent  cases,  especially  in  children,  reduction 
without  an  anesthetic  is  easy,  by  reversing  the  steps  by  which  the 
lesion  was  produced:  first  hyperextend  the  elbow,  until  the  tip  of 
the  olecranon  strikes  the  humerus,  and  the  coronoid  is  freed  from  the 
trochlea;  then  make  extension  and  counter-extension  in  the  axis 
of  the  arm,  pushing  the  lower  end  of  the  humerus  backward;  and 
finally  acutely  flex  the  elbow,  when  the  bones  will  be  replaced  with  a 
snap.     Often  the  pressure  of  the 

thumbs  over  the  lower  end  of  the  ^~^- "~--—    ?v~v^ 

humerus,  and  that  of  the  clasped  (4^=^=i======^ 

fingers  over  the  posterior  surface  /    j/^~~T\      \   ^ 

of  the  olecranon,  is  sufficient  to     r.         /   /I    £  '    \      \  , 
secure  reduction  (direct  method) '{  rf  /     /   -^         \ 

or  the  knee  may  be  placed  in  the         p>\   /    §  \ 

bend  of  the  elbow  and  used  as  a        f '  "«    /  /     &  \   « 

fulcrum  to  lever  the  bones  of  the        Av  -**  \      S        L 
forearm  away  from  the  humerus  V*  \\ 

by  traction  on  the  wrist  with  one  >  % 

hand,  while  the  humerus  is  pushed 

backward     with     the     Other     hand  FlG-.  454  —Mechanism  of  reduction   of 

,„        At-*\       rm         n  •       i  i       posterior  dislocation  of    elbow    by  aid  of 

(rig.  4o4).     Ihe  elbow  is  dressed     the  knee. 

in   hyperflexion    (p.   384),    for    a 

week,   and  then  carried  in  a  sling  for  another,  and  after  two  weeks 

guarded  active  use  is  encouraged. 

Lateral  Dislocation.— External  dislocation  often  is  due  to  direct 
violence,  usually  is  incomplete  and  complicated  by  fracture  of  the 
external  condyle,  and  extensive  rupture  of  the  internal  lateral  ligament 
(Fig.  455).  Internal  dislocation  is  rarer  than  external,  and  fracture  is  a 
less  usual  complication  (Fig.  456).  In  both  forms  the  deformity  is 
so  extreme  and  the  bony  processes  so  easily  palpable  that,  if  careful 
examination  is  made  before  swelling  obscures  the  landmarks,  the 
diagnosis  should  not  be  difficult.  Reduction  is  easier  to  secure  than 
to  maintain,  especially  if  fracture  exists.  The  elbow  should  be  dressed 
in  hyperflexion  and  treated  as  if  fractured. 

Forward  Dislocation. — Forward  dislocation  of  both  bones  at  the 
elbow  is  very  rare;  even  including  seven  cases  in  which  the  olecranon 
was  broken  off  and  remained  in  place,  the  total  number  on  record, 
according  to  Stimson  (1917),  is  less  than  twenty-five.  Fracture  of 
the  epitrochlea  is  a  frequent  accompaniment.  Reduction  is  not 
difficult,  as  both  lateral  ligaments  are  lacerated. 


138  /  VJURIES  OF  JOINTS 

Dislocation  of  the  Ulna  Alone  from  the  humerus  is  most  often  pos- 
terior; the  symptoms  and  treatment  arc  much  the  same  as  when  both 
bones  are  so  displaced. 


Fig.  455.      External  lateral  disloca-  Fig.  4.16. — Inward  dislocation  of  ulna  and 

tion  of  elbow,  with  fracture  of  external  radius.     Dr.  De Tar's  case.     Patient  fell  and 

condyle,  and  rupture  of  internal  lateral  while  lying  on    left    elbow    train    struck    him 

ligament  and    fracture  of    epitrochlea.  upon  buttocks.     Reduction  easy  under  anes- 

Dr.    W.     Walker's     case.      Episcopal  thetic. 
Hospital. 

Dislocation  of  the  Head  of  the  Radius  usually  occurs  in  an  anterior 
direction.  The  orbicular  ligament  may  remain  intact,  the  radius  slipping 
out  of  its  grasp,  and  subsequently  being  displaced  forward  by  the  pull 
of  the  biceps;  often  it  is  the  result  of  a  fracture  of  the  upper  part  of  the 
shaft  of  the  ulna,  from  direct  violence,  the  continuance  of  the  fractur- 
ing force  driving  the  head  of  the  radius  forward  (Figs.  457  and  458). 
This  combined  lesion  is  so  frequent  that  the  recognition  of  either  a 
dislocation  of  the  radial  head  or  a  fracture  of  the  upper  end  of  the  ulna 
should  make  the  surgeon  suspect  the  existence  of  the  complicating 
lesion  (Ashhurst,  1912).  Examination  may  detect  a  hollow  in  front 
of  the  external  condyle,  and  the  head  of  the  radius  a  little  forward 
from  its  normal  position ;  flexion  of  the  elbow  beyond  a  right  angle  may 
be  prevented  by  contact  of  the  radius  with  the  humerus.  Reduction 
sometimes  may  be  secured  by  full  supination  and  direct  pressure 
upon  the  displaced  bone;  and  flexion  will  then  become  possible. 
Reduction  should  be  obtained  at  all  hazards,  by  arthrotomy  if  neces- 
sary. Only  after  reduction  of  the  radial  dislocation  has  been  secured 
can  the  fracture  of  the  ulna  be  reduced.  If  re-dislocation  of  the  radial 
head  occurs  after  keeping  the  elbow  hyperflexed  (p.  347)  for  several 
weeks,  it  may  be  assumed  that  the  radial  head  had  not  been  replaced 
within  the  orbicular  ligament;  and  an  operation  may  be  necessary 
to  hold  it  in  place.  In  cases  of  complete  dislocation  it  is  very  unlikely 
that  reduction  can  be  secured  without  operation.  In  old  unreduced 
luxation,  excision  of  the  radial  head  may  be  done  to  permit  flexion 


dislocation  of  the  radws 


439 


of  the  elbow,  but  in  children  this  should  be  avoided  if  possible,  since 
removal  of  the  epiphysis  will  interfere  with  development. 

In  young  children  a  .subluxation  known  as  "pulled  elbow"  occurs: 
this  is  due  to  vertical  traction  on  the  forearm,  often  produced  as  the 
caretaker  helps  or  lifts  the  child  across  an  obstruction  in  the  street.    If 


Fig.  457. — Anterior  and  outward  dislocation  of  head  of  radius,  with  fracture  of 
shaft  of  ulna.     Four  months  after  injury.     Episcopal  Hospital. 


Fig 


458. — Anterior  and  outward  dislocation  of  head  of  radius,  three  months  after 
reduction  by  arthrotomy  and  capsulorrhaphy.     Episcopal  Hospital. 


the  forearm  is  supinated  the  vertical  traction  tends  to  bring  the  fore- 
arm and  arm  into  a  straight  line,  causing  momentary  loss  of  the  carry- 
ing angle;  or  forced  pronation  may  pry  the  radius  forward  over  the 
ulna  as  a  fulcrum.  C.  A.  Stone  (1916)  thinks  this  is  always  the 
mechanism,     since    in   pronation   the    lesser    diameter    of   the    oval 


lit) 


INJURIES  OF  JOINTS 


head   presents.    Symptoms  of  "pulled  elbow'5  are  rather  indefinite, 

and  in  many  cases  no  definite  history  of  trauma  can  be  obtained;  it 
is  merely  noticed  that  the  arm  is  not  used  properly,  and  that  there  is 
tenderness  around  the  elbow.  Treatment  of  "pulled  elbow"  consists 
in  securing  reduction  of  the  subluxated  bone  by  the  same  methods 
employed  in  cases  of  complete  dislocation,  and  in  preventing  recurrence 
(which  is  not  very  rare)  by  keeping  the  elbow  at  rest  for  a  week. 
Sometimes  a  lesion  of  the  lower  radio-wlnar  joint  co-exists. 

Wrist. — Dislocation  of  the  radio-carpal  joint,  usually  consisting 
in  dorsal  displacement  of  the  carpus,  is  very  rare;  Stimson  classes 
Barton's  fracture  (p.  392)  more  as  a  complication  of  this  dislocation 
than  as  an  independent  lesion.  It  is  produced  usually  by  the 
same  injuries  as  Colles's  fracture,  and  the  differential  diagnosis  is 
not  always  easy;  but  if  it  is  possible  to  feel  the  styloid  processes  of 
the  radius  and  ulna  still  attached  to  their  respective  bones,  and  to 
ascertain  that  the  length  of  the  bones  of  the  forearm  remains  the  same 
on  both  sides  of  the  body  and  to  feel  the  very  abrupt  eminence  on 
the  dorsum  caused  by  the  displaced  carpal  bones,  confusion  between 
fracture  and  dislocation  is  not  apt  to  occur.  Besides,  the  luxation 
is  reduced  by  an  elastic  snap,  without  crepitus,  and  without  tendency 
to  recurrence.    I  have  seen  one  case  myself,  easily  diagnosed  clinically 

by  attention  to  these  details.     The  diagnosis 
may  be  confirmed  by  a  skiagraph. 

Spontaneous  Subluxation  of  the  Wrist 
(Madelung's   Disease). — See  p.  585. 

Dislocations  of  the  carpal  bones  are  not 
very  uncommon,  particularly  forward  dis- 
location of  the  semilunar,  associated  or  not 
with  fracture  of  the  scaphoid.  The  bone 
is  palpable  under  the  flexor  tendons,  and 
there  is  a  gap  on  the  extensor  surface  be- 
tween the  os  magnum  and  radius.  The 
other  carpal  bones,  most  often  scaphoid  or 
os  magnum,  usually  are  dislocated  back- 
ward. If  reduction  is  not  easily  secured, 
the  displaced  bone  should  be  excised. 

Metacarpus.  —  The  metacarpal  bones 
rarely  are  luxated,  the  displacement  usually 
being  posterior. 

Phalanges. — The  proximal  phalanx  of  the 
thumb  not  infrequently  is  dislocated  poste- 
riorly on  the  head  of  its  metacarpal  bone  by  hyperextension,  some- 
times in  a  fight,  a  fall,  or  in  the  effort  to  push  a  tight  stocking  off  the 
heel  of  the  foot.  The  deformity  is  quite  characteristic  (Fig.  459),  the 
phalanx  in  well-marked  cases  making  a  distinct  angle  with  the  meta- 
carpal bone,  the  head  of  which  is  easily  palpable  in  front;  the  distal 
phalanx  remains  flexed,  owing  to  tension  on  the  flexor  longus 
pollieis,    which    is    displaced    to   one     side    or     other,    usually  the 


Fig.  459.  —  Dislocation  of 
metacarpophalangeal  joint  of 
thumb.  Reduced  by  arthro- 
tomy.     Episcopal  Hospital. 


DISLOCATION  OF   THE  HIP 


441 


ulnar  side  of  the  metacarpal.  The  head  of  the  metacarpal  is 
"button-holed"  through  the  anterior  ligament;  the  tendons  of  the 
flexor  brevis  blend  with  the  lateral  ligaments,  and  it  is  the  tension  of 
these  lateral  ligaments,  which  fit  like  a  collar  around  the  neck  of  the 
metacarpal,  that  may  render  reduction  impossible.  In  some  cases 
reduction  can  be  effected  without  anesthesia,  (1)  by  pressing  the 
metacarpal  bone  toward  the  palm,  so  as  to  relax  the  short  thumb 
muscles;  (2)  by  sliding  the  base  of  the  phalanx  over  the  head  of  the 
metacarpal,  keeping  the  phalanx  in  hyperextemion  until  the  head  of 
the  metacarpal  has  been  cleared.  If  reduction  is  impossible,  an 
incision  is  made  along  the  radial  border  of  the  flexor  surface  of  the 
prominent  head  of  the  thumb  metacarpal,  and  the  external  lateral 
ligament  is  divided  close  to  the  phalanx. 

Dislocations  of  the  interphalangeal  joints  of  the  fingers  almost 
always  takes  place  posteriorly,  from  hyperextension,  in  falls  or  blows 
on  the  finger  tips  (Fig.  460).  Reduction  •usually  is  easy,  but  a  joint 
fracture  of  the  proximal  bone  may  exist,  and  some  deformity  may 
result.  Treatment  is  the  same  as  for  fracture  of  a  phalanx.  Lateral 
dislocation  usually  is  incomplete  (Fig.  461). 


Fig.  460. — Posterior  dislocation  of 
middle  phalanx  on  proximal  of  fifth 
finger.      Episcopal  Hospital. 


Fig.  461. — Lateral  dislocation  of  mid- 
dle on  proximal  phalanx.  Episcopal 
Hospital. 


Sacro-iliac  Joints. — Complete  luxation  is  rare,  but  subluxation, 
from  sprain  or  long-continued  strain  may  take  place.  Motion  occurs 
antero-posteriorly  around  a  transverse  axis,  and  the  usual  displace- 
ment is  of  the  upper  end  of  the  sacrum  backward.  Cricks  and  stitches 
in  the  small  of  the  back,  or  severe  backache  may  follow  strain  on 
these  joint  ligaments  from  stooping,  from  malposition  in  sitting  or 
standing,  or  simply  from  lying  long  flat  on  the  back,  when  the  mus- 
cular support  is  weakened  by  anesthesia  or  constitutional  disease. 
Relaxation  of  these  joints  sometimes  is  seen,  and  is  best  treated  by 
orthopedic  apparatus,  gymnastics,  etc.  (p.  57S). 

Hip. — Dislocation  of  the  hip  is  a  rare  and  rather  a  serious  injury. 
The  head  of  the  femur  is  held  in  the  acetabulum  by  a  capsular  ligament 
which  is  reinforced  above  and  below  by  band-like  ligaments,  leaving 
the  capsule  weak  anteriorly  and  posteriorly.  The  upper  band-like 
ligament  (ilio-femoral  ligament  of  Bertin,  1754)  is  especially  strong, 
and  is  known  as  the  Y-ligament  of    Bigelow  (1869);  it  is  scarcely 


442 


INJURIES  OF  JOINTS 


Fig.  462. — Innominate  hone  showing  the 
anterior  and  posterior  planes.  University  of 
Pennsylvania. 


ever  ruptured,  no  matter  what  the  force  thai  produces  the  luxation. 
Indirect  violence  is  the  usual  cause,  the  femur  being  forced  beyond 
its  normal  range  cither  in  flexion  and  adduction,  or  in  extension  and 
abduction,  and  the  head  of  the  hone  being  pried  out  of  the  acetabulum 
by  leverage.  In  the  cadaver  luxations  are  most  easily  produced  by 
hyperabduction,   forcing  the   ureal   trochanter  against    the  posterior 

lip  of  the  acetabulum,  and  using 
it  as  a  fulcrum  by  which  the 
head  is  lifted  out  of  its  socket; 
the  capsule  is  then  ruptured 
anteriorly  below  the  ilio-femoral 
ligament,  and  the  head  of  the 
bone  passes  on  to  the  anterior 
plane1  of  the  innominate  bone 
(Fig.  4('i2).  In  patients,  how- 
ever, the  history  of  the  injury 
generally  indicates  another  me- 
chanism, the  femur  having  been 
in  flexon  and  adduction,  and 
the  force  having  been  received 
through  an  upward  thrust  in  the 
long  axis  of  the  femur,  or  by  a  heavy  weight  falling  on  the  pelvis 
from  behind.  In  such  cases  it  is  probable  that  the  strong  ilio- 
femoral ligament  has  been  wound  around  the  neck  of  the  femur 
(inwardly  rotated),  acting  as  a  sliding  fulcrum;  or  possibly  that  the 
neck  of  the  femur  has  been  forced  against  the  horizontal  ramus  of 
the  pubis,  and  that  the 
head  has  been  pried  out 
of  the  acetabulum  over 
this  as  a  fulcrum.  The 
capsule  here  is  ruptured 
posteriorly,  and  the  fe- 
moral' head  passes  on  to 
the  posterior  plane  of  the 
innominate  bone.  Owing 
to  the  immense  length 
of  the  distal  arm  of  the 
lever  (the  whole  lower  ex- 
tremity), it  is  not  at  all 
unusual  for  a  dislocation 
primitively  anterior  to  be 

converted'  into  one  of  the  posterior  variety  consecutively ;  in  such  cases 
the  capsule  may  be  widely  lacerated,  but  in  almost  every  case  the  ilio- 
femoral ligament  remains  intact,  and  the  lower  extremity  is  circum- 
ducted and  rotated  on  it  as  a  pivot. 

In  general,  then,  two  main  types  of  dislocation  at  the  hip  may  be 


Fig.  463. — Usual  sites  of  dislocation  at  the  hip. 
A  to  B,  Negation's  line.  Posterior  dislocations  are 
(1)  low;  (2)  high.  Anterior  dislocations  are:  (3)  low; 
(4)  high.     See  text. 


Nekton's  line  divides  the  innominate  bone  into  two  planes  (Allis,  1896). 


DISLOCATION  OF   THE  11 W 


li:; 


recognized,  anterior  and  posterior;  and  of  each  type  there  are  several 
varieties,  according  as  the  head  of  the  femur  rests  high  or  low  on  the 
anterior  or  posterior  plane  of  the  pelvis  (Fig.  463). 

Posterior  Dislocations  of  the  Hip,  more  frequent  than  anterior,  are 
classed  as  high  ("  dislocation  on  the  dorsum  ilii,"  or  "  above  the  tendon" 


Fig.  464. — Posterior  (dorsal)  dislocation  of  the  hip.     (Stimson.) 

of  the  obturator  interims),  and  low  ("  dislocation  into  the  sciatic  notch" 
of  Sir  Astley  Cooper,  1822;  or  "below  the  tendon"  of  Bigelow  1869); 
and  of  these  two  the  high  luxation  is  much  more  frequent,  though 
this  may  be  only  a  consecutive  displacement,  the  head  of  the  femur 
having  emerged  from  the  capsule  lower  than  the  sciatic  notch,  and 
having  been  displaced  upward  when  the  limb  was  extended. 


•II! 


INJURIES  OF  JOINTS 


Symptoms.  There  is  loss  of  normal  mobility;  there  is  shortening, 
with  flexion,  adduction  and  internal  rotation  at  the  hip;  and  in  stand- 
ing the  toes  of  the  injured  side  rest  on  the  dorsum  of  the  other  foot 
i  Fig.  164).  The  lower  the  position  of  the  femoral  head  on  the  posterior 
plane,  the  more  marked  will  be  the  shortening,  flexion,  adduction, 
and  inward  rotation.  The  head  of  the  femnr1  can  no  longer  be  felt 
below  Poupart's  ligament,  beneath  the  femoral  artery,  but  sometimes 
can  be  detected  posteriorly  under  the  gluteal  muscles;  the  trochanter 
is  unduly  prominent,  is  rotated  forward,  and  is  above  Nelaton's  line. 

_^^         Anterior  Dislocations  of  the  Hip  are 

>  classed    as    high    ("pubic"),  or    low 

("thyroid"),  the  latter,  in  which  the 
head  rests  in  the  obturator  foramen, 
probably  being  the  primitive  form 
in  most  cases;  in  the  pubic  form, 
the  head  rests  against  the  horizontal 
ramus  of  the  pubis;  an  exaggerated 
form  of  the  high  dislocation  is  the 
"suprapubic,"  and  an  exaggerated 
form  of  the  low  dislocation  is  the 
"perineal,"  the  head  of  the  bone 
passing  inward  beyond  the  thyroid 
foramen  and  across  the  ischium  into 
the  perineum. 

Symptoms. — All  these  anterior  dis- 
locations are  characterized  by  im- 
mobility, flexion,  abduction,  and 
eversion  of  the  limb  (Fig.  405);  in 
the  low  forms  there  may  be  apparent 
lengthening,  but  in  the  high  cases 
there  usually  is  actual  shortening. 
The  head  of  the  femur  generally  can 
be  felt  beneath  the  pectineus  or  ad- 
ductor muscles,  and  often  forms  a 
visible  prominence;  the  trochanter  is 
rotated  backward,  and  is  less  promi- 
nent than  normally. 
Other  Atypical  or  "Irregular"  Dislocations  of  the  Hip  occur,  but  are 
extremely  rare,  and  are  either  secondary  modifications  of  those  de- 
scribed above,  or  are  caused  by  such  violent  trauma  as  frequently  to 
cost  the  patient  his  life.  The  so-called  "central  dislocation  of  the 
hip"  is  discussed  at  p.  301. 

Prognosis. — If  reduction  is  effected  promptly,  and  without  additional 
trauma,  restoration  of  function  is  rapid,  and  generally  complete;  but 
the  longer  reduction  is  delayed,  and  the  greater  the  force  required 

1  A  good  working  rule  to  remember  is  that  the  position  of  the  internal  condyle 
corresponds  to  that  of  the  head  of  the  femur,  while  that  of  the  external  condyle 
corresponds  to  that  of  the  great  trochanter  (G.  G.  Davis,  1910). 


Fig.  465. — Anterior    (thyroid)    dis 
location  of    hip.     Episcopal   Hospital 


DISLOCATION  OF   THE  HIP 


445 


in  accomplishing  it,  the  more  unfavorable  the  outlook.  But  even  in 
some  cases  of  irreducible  luxation,  especially  of  the  thyroid  type,  very 
fair  use  of  the  limb  may  be  secured. 

Treatment. — Reduction  of  dislocation  of  the  hip  is  accomplished 
either  by  the  direct  or  indirect  method. 

Direct  Method. — In  this,  systematized  by  Allis  (1896),  the  head  of 
the  femur  is  first  brought  into  the  position  in  which  it  burst  through 
the  capsule,  and  is  then  pushed  or  pulled  into  the  acetabulum. 
As  in  both  anterior  and  posterior  dislocations  the  head  leaves  the 
acetabulum  in  its  lower  part,  and  as  the  capsule  probably  is  widely 
torn  below,  the  method  of  direct  reposition  is  nearly  the  same  for  both 
varieties.     The  patient  should  be  anesthetized  and  laid  on  his  back 


Fig.  466. — Position  of  bones  in  reduction  of  posterior  dislocation  of  hip  by  direct 
method.     University  of  Pennsylvania. 

on  a  mattress  on  the  floor,  with  the  pelvis  firmly  fixed :  flex  the  thigh 
on  the  pelvis  to  a  right  angle,  thus  bring'ng  the  head  of  the  femur 
toward  the  lower  part  of  the  acetabulum;  flex  the  knee  to  a  right  angle, 
to  relax  the  hamstring  muscles  and  sciatic  nerve,  and  to  aid  in  rotating 
the  thigh.  Hold  the  ankle  with  one  hand,  and  pass  the  other  hand 
beneath  the  flexed  knee  or  sling  a  towel  under  the  knee  and  over  your 
own  shoulders,  to  aid  in  the  upward  traction  required.  In  backward 
dislocation  have  the  thigh  slightly  addicted,  to  free  the  head  from 
the  rim  of  the  acetabulum  and  to  relax  the  anterior  branch  of  the 
Y-ligament;  then  make  vertical  traction  on  the  thigh  upward  and 
a  little  inward,  and  the  head  may  jump  into  the  acetabulum  (Fig. 
400).  If  it  does  not,  rotate  the  thigh  gently  in  and  out  (do  not 
circumduct  it),  to  make  the  capsule  gape  widest,  and  try  to  pull 


1 16 


l\.ll  HIES   OF  JOISTS 


the  head  over  the  rim  of  the  acetabulum  in  the  various  positions 
of  rotation.  An  assistant  may  help  by  direct  pressure  upward 
and  inward  on  the  great  trochanter.  The  head  usually  will  jump 
into  the  acetabulum  with  an  audible  snap.  In  forward  dislocation, 
have  the  thigh  slightly  abducted,  to  free  the  head  from  the  antero- 
inferior margin  of  the  acetabulum,  and  to  relax  the  posterior  branch 
of  the  Y-ligament;  then  make  vertical  traction  upward  and  slightly 
outward,  and  the  head  often  will  jump  into  the  acetabulum  (Fig.  467). 
If  not,  gentle  rotation  may  be  tried,  until  the  capsule  gapes  its  widest; 
and  an  assistant  may  aid  by  pushing  the  trochanter  upward  and 
slightly  outward. 


Fig.  467.- 


-Position  of  bones  in  reduction  of  anterior  dislocation  of  hip  by  direct 
method.     University  of  Pennsylvania. 


In  Stimson's  application  of  the  direct  method  (1889)  for  posterior 
dislocation,  the  patient  lies  prone,  with  the  affected  thigh  hanging 
vertically  downward:  the  knee  of  the  dislocated  side  is  flexed,  and 
the  ankle  held  by  the  surgeon;  in  most  cases  the  weight  of  the  limb 
is  sufficient  to  reduce  the  dislocation  within  a  few  minutes  without 
pain  and  almost  imperceptibly;  if  necessary,  weight  may  be  added  to 
the  knee,  and  gentle  rotation  practiced,  as  when  the  patient  lies  on 
his  back. 

Indirect  Method. — Reduction  by  manipulation  alone  was  taught 
and  practised  by  Hippocrates,  N.  R.  Smith  (1831),  and  Despres 
(1835),  and  was  systematized  by  W.  W.  Reid  (1851);  they  regarded 
the  muscles  as  the  chief  obstacles  to  reduction;  but  it  remained  for 
Moses  Gunn  (1853)  and  especially  for  Bigelow  (1869)  to  demonstrate 


DISLOCATION  OF   THE  HIP 


44; 


that  even  with  muscular  contraction  abolished  by  anesthesia,  the 
capsule  still  remained  the  supreme  obstacle,  and  that  manipulation 
was  successful  only  when  the  action  of  the  Y-ligament  was  appreciated 
and  employed  as  an  aid.  It  is  used  as  a  sliding  fulcrum  over  which 
the  head  of  the  femur  rides  into  the  acetabulum.  The  patient  is 
anesthetized,  and  laid  on  his  back  on  a  mattress  on  the  floor;  with 
the  pelvis  firmly  fixed,  the  thigh  is  flexed  on  the  pelvis  to  relax  the 
Y-ligament  and  to  bring  the  head  of  the  bone  down  to  the  lower 
part  of  the  acetabulum  near  the  rent  in  the  capsule;  and  the  leg  is 
flexed  on  the  thigh  to  aid  in  the  manipulation,  and  to  relax  the  ham- 
strings and  sciatic  nerve.  In  posterior  dislocations  the  limb  is  brought 
up  in  the  position  in  which  it  is  found  (adduction),  and  is  gently  circum- 
ducted and  rotated  outward  after  the  thigh  has  been  flexed  to  more 
than  a  right  angle  with  the  pelvis;  as  outward  circumduction  is  con- 
tinued (Fig.  4GS),  the  head  of  the  bone  is  swung  downward  and  inward 
by  tension  on  the  posterior  branch  of  the  Y-ligament,  and  finally 


Fig.  468. — Reduction  of  backward  dis- 
location of  femur.      (Bigelow.) 


Fig.    469. — Reduction   of   downward    and 
forward  dislocation  of  femur.   (Bigelow.) 


as  the  limb  is  brought  down  to  the  position  of  full  extension  and 
very  slight  abduction,  the  head  rides  over  the  rim  of  the  acetabulum 
and  sinks  into  its  socket.  7/  the  abduction  is  too  great  as  the  thigh  is 
brought  down  to  extension,  the  head  will  slide  across  to  the  anterior 
plane  of  the  pelvis,  and  a  consecutive  thyroid  luxation  will  be  produced. 
Rarely  in  this  excursion  the  sciatic  nerve  may  be  caught  up  over  the 
neck  of  the  femur.  If  abduction  is  not  great  enough,  the  head  will 
slide  up  again  on  the  outer  side  of  the  acetabulum,  and  the  high 
posterior  luxation  will  be  reproduced.  Rarely  as  it  slides  up  it  may 
catch  under  the  tendon  of  the  obturator  internus.  In  anterior  dis- 
locations the  limb  is  brought  up  in  the  position  in  which  it  is  found 
(abduction),  and  is  gently  circumducted  and  rotated  inward  after 
the  thigh  has  been  flexed  to  more  than  a  right  angle  with  the  pelvis; 
as  inward  circumduction  is  continued  (Fig.  469),  the  head  of  the  bone 
is  swung  downward  and  outward  by  tension  on  the  anterior  branch 
of  the  Y-ligament;  and  finally  as  the  limb  ig  brought  down  to  the 


448  INJURIES  OF  JOINTS 

position  of  full  extension  and  very  slight  adduction,  the  head  rides 
over  the  rim  of  the  acetabulum  into  its  socket.  //  the  add  net  ion  is 
too  gnat,  a  consecutive  posterior  dislocation  may  be  produced;  and 
if  it  is  not  great  enough,  the  head  will  slide  up  the  inner  side  of  the 
acetabulum  to  a  pubic  position. 

Reduction  is  known  to  have  been  accomplished  when  the  head 
of  the  bone  is  felt  to  snap  into  place,  and  it  can  be  felt  rotating  in 
its  socket  by  the  fingers  below  Poupart's  ligament;  when  normal 
extension  of  the  hip  is  possible,  and  when  a  skiagraph  shows  the 
bones   in   place. 

After-treatment. — The  patient  should  be  kept  in  bed  with  moderate 
weight-extension  for  a  couple  of  weeks,  and  should  resume  use  of 
the  limb  with  caution. 

Patella.  Outward  luxation  of  the  patella  was  mentioned  at  p.  310 
as  a  rare  complication  of  marked  knock-knee  deformity,  and  of  some 
paralytic  conditions  when  it  is  a  recurrent  or  habitual  dislocation; 
it  is  also  seen  very  occasionally  as  a  traumatic  lesion.  Rotatory  forms 
of  luxation  of  the  patella  also  occur,  usually  from  injury;  these  almost 
invariably  occur  outward,  that  is,  the  anterior  surface  of  the  patella 
faces  first  outward,  and,  if  the  luxation  is  complete,  then  it  turns 
completely  over  until  the  joint  surface  presents  subcutaneously.  A 
downward  luxation,  associated  with  rupture  of  the  quadriceps,  also 
has  occurred,  the  patella  being  wedged  between  femur  and  tibia.  If 
reduction  by  manipulation  fails,  arthrotomy  should  be  done. 

Knee.— Traumatic  luxations  of  the  knee  are  extremely  rare,  and 
usually  caused  by  very  severe  injuries.  The  displacement  of  the 
head  of  the  tibia  may  be  backward,  forward,  lateral,  or  rotatory. 
Wise  (1909)  refers  to  270  cases  of  dislocation  of  the  knee,  114  of  which 
were  anterior.  Most  of  the  displacements  are  incomplete,  the  lateral 
almost  invariably.  Forward  dislocation  is  caused  by  sudden  violent 
hyperextension,  by  indirect  or  direct  violence;  the  tibia  slides  up 
on  the  front  of  the  condyles,  but  usually  maintains  the  same  axis 
as  the  femur,  not  being  flexed  or  hyperextended.  Backward  dis- 
location usually  follows  direct  force  applied  to  the  front  of  the  tibia, 
and  the  leg  becomes  hyperextended  on  the  thigh.  In  many  of  these 
luxations  injuries  to  the  popliteal  vessels  or  nerves  are  present,  and 
the  intra-articular  cartilages  and  ligaments  may  be  ruptured.  Usually 
reduction  is  not  very  difficult,  owing  to  stretching  or  laceration  of 
the  lateral  ligaments.  Prognosis  as  to  function  is  not  very  good 
even  in  uncomplicated  cases,  some  deformity  (flexion,  valgus,  etc.), 
generally  persisting  through  life;  and  for  complications,  amputation 
may  be  required. 

Internal  Derangement  of  the  Knee-joint  (I ley,  1803).— Several  lesions 
are  grouped  under  this  heading : 

Fracture  or  Subluxation  of  the  Semilunar  Cartilages-,  usually  the 
internal,  has  as  its  most  frequent  cause  a  fall  with  the  knee  in  flexion 
and  the  tibia  in  outward  rotation;  if  this  process  increases,  the  anterior 
crucial  ligament  may  be  ruptured;  if  the  fall  occurs  when  the  knee  is 


INTERNAL  DERANGEMENT  OF  THE  KNEE-JOINT 


449 


flexed  and  the  tibia  in  internal  rotation,  avulsion  of  the  tibial  spine 
may  result  (Figs.  471  and  472).  The  patients  often  are  not  seen  until 
some  time  after  the  original  accident,  and 
demand  relief  from  recurrent  disability: 
thus  there  may  be  repeated  locking  of 
the  knee  in  flexion  from  slight  sprain. 
This  may  be  due  to  dislocation  of  a  semi- 
lunar cartilage  (Fig.  470),  to  the  presence 
of  joint  mice  (p.  502),  or  a  loose  fragment 
of  bone.  Sometimes  the  lump  becomes 
palpable.  According  to  Alwyn  Smith 
(1918)  when  the  knee  is  in  full  extension, 
the  possibility  of  anterior  displacement  of 
the  tibia  on  the  femoral  condyles  indicates 
rupture  of  the  anterior  crucial  ligament, 
while  backward  displacement  indicates  the 
posterior  crucial  is  ruptured.  With  the 
former  lesion  relaxation  of  the  internal 
lateral  ligament  is  frequent,  causing  a  ten- 
dency toward  genu  valgum. 


Fig.  470. — External  semilunar 
cartilage  removed  from  knee,  for 
dislocation.    Episcopal  Hospital. 


Fj<;.  471. — Fracture  nf  spine  of  tibia.     Episcopal  Hospita 


29 


450  INJURIES  OF  JOINTS 

Treatment. — As  a  rule  gentle  manipulation  and   gradual   passive 
extension  so  far  as  possible,  followed  by  sudden  acute  flexion  of  the 


Fig.  472. — Same  as  Fig.  471.     Patient  completely  relieved  by  excision  of  detached 
fragment  and  suture  of  anterior  crucial  ligaments. 


Fig.  473. — Arthrotomy  of  knee.     Exposure  secured  by  longitudinal  section  of  patella. 
University  of  Pennsylvania. 

knee  will  reduce  the  deformity,  and  restore  the  movements  of  the 
joint.     After  reduction  of    the    displacement,  some  appliance  must 


DISLOCATION  OF   THE  ANKLE 


451 


be  worn  to  limit  motion  in  the  knee  and  prevent  rotation  of  the 
tibia.  If  the  patient  is  anxious  for  a  radical 'cure,  arthrotomy  may 
be  done,  preferably  by  longitudinal  section  of  the  patella  (Jones  and 
Smith,  1913),  which  gives  the  best  possible  exposure  for  any  procedure 
that  may  be  indicated  (Fig.  473).  A  luxated  or  fractured  cartilage 
should  be  excised;  attempts  to  suture  it  in  place  are  not  advisable. 
Function  nearly  always  is  completely  restored.  Hey  Groves  (1917)  and 
Ahvyn  Smith  (1918)  have  used  strips  of  fascia  lata  to  replace  the 
anterior  crucial  ligament. 


Fig.  474. — Skiagraph  of  fracture-dislocation  of  astragalus.  Age  forty-five  years. 
From  fall  of  eight  feet,  landing  on  feet.  Irreducible.  Both  fragments  excised.  Excel- 
lent result.     Episcopal  Hospital. 


Ankle.  (Tibio-tarsal  Joint). — Except  in  connection  with  fracture 
of  the  leg  bones,  dislocations  at  the  ankle-joint  are  exceedingly  rare. 
Wendel  (1898)  collected  108  cases  without  fracture.  Posterior  luxa- 
tion usually  follows  forced  plantar  flexion  of  the  foot,  with  rupture 
of  the  lateral  ligaments  of  the  ankle,  the  astragalus  sliding  backward 
off  the  tibio-fibular  mortise  as  dorsal  flexion  is  regained.  Anterior 
luxation,  much  rarer,  usually  occurs  when  the  foot  is  in  extreme 
dorsal  flexion,  the  leg  bones  being  forced  backward  against  the  tense 
tendo  Achillis  either  by  a  blow  from  above  or  by  a  fall  on  the  heel. 
Lateral  dislocation  is  that  in  which  the  astragalus  and  with  it  the 
foot,  leaves  the  tibio-fibular  mortise,  and  is  displaced  externally  or 
internally,  there  being  little  or  no  rotation  of  the  foot.  A  less  unusual 
displacement  is  that  in  which  the  astragalus  rotates  around  an  antero- 
posterior axis,  so  that  the  sole  of  the  foot  looks  either  inward  (sicpina- 


452 


INJURIES  OF  JOINTS 


Hon  dislocation)  or  outward  {pronation  dislocation).  If,  on  the  other 
hand,  the  astragalus  rotates  around  a  vertical  axis,  it  may  remain 
in  the  tibio-fibular  mortise,  but  the  entire  foot  may  rotate  with  it 
the  toes  looking  inward  and  the  heel  outward  in  dislocation  by  inver- 
sion, and  the  opposite  being  the  case  in  dislocation  by  eversion.  Dis- 
location upward  (the  astragalus  separating  the  tibia  and  fibula)  is 
known  by  Nelaton's  name,  though  his  case  was  complicated  by 
fracture.  Unless  swelling  obscures  bony  landmarks,  these  various 
forms  can  be  distinguished  clinically;  but  in  all  cases  it  is  desirable 
to  have  skiagraphs  made  in  at  least  two  planes.  These  dislocations 
about  the  ankle-joint  frequently  are  compound,  and  as  already 
remarked,  fracture  of  some  of  the  bones  involved  very  rarely  is 
absent  (Fig.  436).  Reduction  is  not  always  possible  without  incision, 
and  should  be  accomplished  on  the  day  of  injury  if  possible.  The 
longer  the  bones  remain  out  of  place,  the  less  favorable  will  be  the 
prognosis  for  function. 


Fig.  41 


-Skiagraph  of  upward  dislocation  of  tarsal  scaphoid.     Age  fifty-four  years. 
Episcopal  Hospital. 


Tarsus. — The  astragalus  may  be  the  subject  of  an  isolated  dis- 
location forward  or  backward,  the  latter  being  much  rarer,  and  the 
forward  displacement  usually  being  somewhat  inward  or  outward 
as  well;  or  the  astragalus  may  be  rotated  in  any  axis,  remaining  in 
situ.  If  reduction  is  not  possible  by  manipulation,  aided  perhaps 
by  tenotomy  of  the  tendo  Achillis,  arthrotomy  should  be  done,  and 


DISLOCATION  OF   THE  FOOT 


453 


the  astragalus  removed  unless  reduction  is  easy.  Isolated  disloca- 
tion of  the  other  tarsal  bones  may  occur  (Fig.  475) ;  unless  reduction 
is  easy,  the  displaced  bone  should  be  excised.  Subastragalar  dis- 
location of  the  foot,  of  which  Wise  (1909)  collected  87  examples  (50 
inward,  21  outward,  8  anterior,  and  8  posterior),  consists  of  displace- 
ment of  the  entire  foot  from  the  astragalus,  which  remains  in  the 
tibio-fibular  mortise.  Reduction  usually  is  possible  by  manipulation, 
and  may  be  aided  by  tenotomy  of  the  tibialis  anticus,  or  by  incision,  if 
necessary.     For  compound  dislocations  amputation  may  be  required. 

Dislocation  at  the  medio-tarsal  joint  is  rare.  Skillern  (1913)  reported 
what   he   considered  the  thirteenth  authentic  case   on  record.     The 
anterior  tarsus  may  be  displaced  toward 
the  flexor  or  extensor  surface.     Reduction 
usually  is  possible  by  manipulation  under 
an  anesthetic. 

Metatarsus. — Dislocations  of  the  meta- 
tarsals have  been  studied  at  length  by 
Quenu  and  Kiiss  (1909);  they  collected 
35  cases,  and  believe  that  systematic 
radiographic  study  will  show  it  to  be 
rather  a  frequent  lesion  of  the  foot.  It 
frequently  is  complicated  by  fracture,  and 
usually  is  due  to  direct  violence  or  to 
falls  on  the  toes.  They  show  that  the 
foot  may  be  divided  into  two  structural 
parts,  as  in  Fig.  476,  of  which  the  main 
weight-bearing  part  is  composed  of  the 
tarsus  and  the  first  metatarsal  with  its 
phalanges,  while  the  four  outer  meta- 
tarsals serve  as  a  balance.  The  most 
frequent  luxations  are  (1)  one  in  which 
the  balancing  portion  is  displaced  exter- 
nally and  toward  the  dorsum  of  the  foot 

(external  dorso-lateral  dislocation) ,  and  (2)  one  in  which  there  is  a  dis- 
placement of  the  balancing  portion  outward  and  of  the  first  meta- 
tarsal inward  (divergent  dislocation).  Diagnosis  depends  largely  on 
radiography.  If  reduction  is  impossible  by  manipulation,  operation 
may  be  done ;  this  cannot  be  made  to  conform  to  any  type,  but  may 
involve  tenotomy,  arthrodesis,  removal  of  fragments,  etc.  But  even 
in  cases  not  reduced,  fair  use  of  the  foot  may  be  regained  after 
several  months  or  a  year. 

Phalanges. — Dislocations  of  the  phalanges  of  the  toes  are  rare, 
usually  due  to  direct  violence,  and  hence  often  compound.  Reduction 
and  treatment  are  the  same  as  in  the  fingers. 


Fig.  476. — The  structural  por- 
tions of  the  foot  concerned  in 
metatarsal  dislocations.  (Quenu 
and  Kiiss.) 


CHAPTER  XIV. 
DISEASES  OF  BONE. 

DYSTROPHIES  OF  BONE. 

There  are  numerous  affections  of  bone  of  whose  nature  patholo- 
gists are  still  in  ignorance.  Some  of  them  are  known  to  be  associated 
with  changes  in  the  organs  of  internal  secretion;  some  of  them  may 
be  due  to  remote  infections,  to  chronic  toxemias  or  intoxications; 
but  all  that  is  certain  is  that  they  depend  on  disturbances  of  nutri- 
tion, and  for  that  reason  it  is  convenient  to  group  them  together  as 
dystrophics.  In  most  cases  the  osseous  system  alone  is  not  affected, 
but  is  more  conspicuously  diseased  than  the  soft  tissues.  The  diseases 
in  question  range  from  atrophic  to  hypertrophic  forms,  but  in  many 
both  atrophy  (softening)  and  hypertrophy  (hardening)  are  present 
coincidently,  or  at  different  stages  of  the  same  disease. 

Atrophy  of  Bone. — This.may  be  concentric  or  eccentric  (Fig.  477).  In 
the  former  variety,  which  begins  at  the  periosteal  surface,  the  size  of 
the  bone  decreases,  but  its  length  (due  to  cartilaginous  growth)  is 
little  affected,  and  what  once  was  a  strong  shaft  becomes  a  mere 
spindle.  In  eccentric  atrophy  the  changes  begin  in  the  marrow, 
and,  though  the  bone  may  not  change  in  size,  it  becomes  weaker 
and  more  porous.  In  both  forms  the  pathological  changes  consist 
in  absorption  of  the  bony  trabecular  by  giant  cells  (osteoclasts), 
with  the  deposit  of  fat  in  the  lacunae  (lacunar  resorption).  If  the 
bone  becomes  fragile  and  brittle,  there  is  said  to  be  osteopsathyrosis 
(Lobstein,  1833),  or  fragilitas  ossium;  if  it  merely  becomes  light  and 
porous,  without  tendency  to  fracture,  the  condition  is  known  as 
osteoporosis. 

Causes. — Causes  of  bone  atrophy  are  disuse  (as  in  amputation 
stumps,  paralyzed  limbs,  etc.);  chronic  disease,  especially  of  the 
nervous  system;  and  old  age.  In  most  cases  disuse  is  the  paramount 
cause.  Atrophy  from  pressure  is  also  seen,  as  in  tumors,  aneurysms, 
etc. 

Osteogenesis  Imperfecta  (Vrolik,  1849). — Osteogenesis  imperfecta, 
the  so-called  "idiopathic  fragilitas  ossium,"  is  considered  a  definite 
disease;  it  is  congenital,  may  be  hereditary,  and  patients  seldom  reach 
adult  life.  Lovett  and  Nicholls  found  it  associated  with  changes  in 
the  adrenals  (1906).  Naturally  the  long  bones  of  the  limbs  are  those 
most  often  fractured,  usually  from  no  recognizable  injury;  union 
occurs  without  difficulty,  but  usually  with  deformity  owing  to  the 
frequent  lack  of  splinting.  The  calvaria  may  remain  membranous 
throughout,  or  scattered  bone  islets  may  develop.  The  subject  has 
been  carefullly  studied  by  E.  Bronson  (1917)1 

1  Cretinism  was  separated  from  osteogenesis  imperfecta  by  Heckel  in  1861. 
(454) 


DYSTROPHIES  OF  BONE 


455 


Achondroplasia. — Achondroplasia  (Parrot,  1878),  known  also  as 
ckondrodystrophia  foBtalis  (Kauffman,  1892)  is  a  congenital  affection  in 
which  the  epiphyses  of  the  long  bones  become  ossified  abnormally 
early,  preventing  growth  of  these  bones  in  length,  and  giving  these 
patients  a  typical  appearance:  normal  sized  body  with  dwarf-like 
extremities.     Characteristic  deformities  are  the  trident   hand,  all  the 


Fig.  477. — Extreme  bone  atrophy,  occurring  in  hereditary  syphilis,  in  a  girl,  aged 
eighteen  years,  who  had  not  walked  for  five  years.  The  continuity  of  the  tibia  is  lost, 
that  of  the  fibula  preserved  (concentric  atrophy).  The  tarsal  bones  and  articular 
extremities  of  the  tibia  and  fibula  show  eccentric  atrophy.     Episcopal  Hospital. 

fingers  being  of  the  same  length,  with  a  tendency  toward  bifurcation 
of  the  hand;  and  the  fibula  may  extend  to  the  level  of  the  knee-joint. 
Cartilaginous  exostoses  (p.  485)  may  co-exist.  The  calvaria  (of  mem- 
branous development)  usually  is  unaffected.  Shattuck  classes  it  as 
a  paracretinous  condition,  and  found  it  associated  with  changes  in  the 
thyroid. 

Rachitis. — This  is  a  disease  apparently  dependent  on  malnutrition, 
and  having  its  chief  manifestations  in  the  osseous  system.     It  begins 


456 


DISK  AS  US  OF   HONK 


almost  exclusively  in  young  children  (under  three  years  of  age), 
but  seems  never  to  be  congenital.  The  patients  usually  are  not 
breast-fed,  but  have  been  brought  up  on  improper  milk  mixtures. 
The  osseous  changes  occur  chiefly  in  the  epiphyseal  cartilages,  and 
consist  in  irregular  over-growth  of  cartilage  cells;  some  of  these  car- 
tilaginous islets  may  be  displaced  into  the  metaphysis,  and  cause 
subsequent  trouble  (see  Multiple  Cartilaginous  Exostoses,  p.  485). 
Though  the  cartilage  cells  form  osteoid  tissue,  there  is  deficient  depo- 
sition of  lime  salts,  and  such  as  are  deposited  may  be  removed  by 
lacunar  resorption,  resulting  in  marked  osteoporosis.  When  the 
disease  passes  off,  after  lasting  from  three  to  five  years,  the  bone 
becomes  hard,  dense,  and  eburnated,  and  deformities  developed 
during  the  earlier  period  become  permanent. 

Symptoms. — Early  in  the  disease,  attention  may  be  drawn  to  the 
infant  on  account  of  constant  fretfulness,  sweating  about  the  head, 
backwardness  in  walking  or  even  crawling,  inability  to  sit  up  alone, 
delayed  dentition,  etc.  In  extreme  cases  the  limbs  are  very  painful, 
and  pseudo-paralysis  may  be  present.     When  physical  signs  begin 

to  develop,  among  the  most  constant 
and  conspicuous  is  enlargement  of  the 
epiphyseal  cartilages  (Fig.  478),  ap- 
preciable especially  at  the  wrist,  ankle- 
and  costo-sternal  joints,  the  deformity 
in  the   last    named    situation   being 


Fig.  478.  —  Rachitis.  Age  five 
years.  Scarcely  able  to  walk  alone. 
Children's  Hospital. 


Fig.  479.  —  Rachitis.  Age  two  years. 
Showing  how  bow-legs  develop  from  persist- 
ent malposition.     Children's  Hospital. 


called  the  "rachitic  rosary."  The  head  appears  square,  the  forehead 
is  high,  and  the  fontanelles  remain  open  to  the  third  or  fourth  year. 
The  thorax  may  present  a  transverse  depression  (Harrison's  groove, 
1820)  from  the  constant  tug  of  the  diaphragm  on  the  softened  ribs. 


RACHITIS 


457 


The  child  is  "pot  bellied,"  and  there  may  be  a  long,  rounded  kyphosis 
of  the  spine,  which  disappears  completely  on  hyperextension;  the  spine 
is  nowhere  rigid.  Various  deformities  of  the  extremities  develop,  due 
to  malposition  and  pressure  (Fig.  479).  "  Knock-knee"  or  genu  valgum 
usually  is  due  to  changes  in  the  lower  femoral  epiphysis,  with  over- 
growth of  the  internal  condyle,  increasing  the  normal  outward  deviation 
of  the  leg;  "out-knee"  or  genu  varum  is  a  less  usual  deformity  than 
"bow-legs,"  in  which  the  main  deformity  is  in  the  leg  bones.  Knock- 
knee  and  bow-leg  may  coexist  (Fig.  480) ,  generally  due  to  the  mother 
carrying  the  child  constantly  on  the  same 
arm  (that  side  on  which  knock-knee 
develops)  instead  of  alternating  on  the 
right  and  left.  Anterior  curvature  of  the 
tibia'  is  a  conspicuous  deformity,  but 
very  slightly  disabling.  Rachitic  coxa 
vara  is  one  of  the  less  usual  deformities. 
Rachitic  deformity  of  the  pelvis  may  in- 
terfere with  parturition. 

Treatment. — In  early  stages  constitu- 
tional treatment  is  most  important,  and 
may  be  successful  in  preventing  develop- 
ment of  deformities.  The  diet  must 
be  regulated,  and  as  soon  as  the  child 
can  be  weaned,  a  generous  mixed  diet, 
with  plenty  of  vegetables,  is  preferable 
to  continuance  with  milk;  of  all  tonics, 
exclusive  of  fresh  air,  cleanliness,  and 
sunlight,  which  of  course  must  be  pro- 
vided, none  is  so  good  as  cod  liver  oil; 
this  (not  an  emulsion,  but  the  pure 
Norwegian    oil)    may  be    given    three 

in   doses   from   2  or  3  c.c. 

quantity  that  can  be  ab- 
sorbed. In  the  very  exceptional  cases 
in  which  this  is  not  tolerated,  the  syrup 
of  the  iodide  of  iron  may  be  substituted ; 
and  in  many  cases  phosphates  should 
be  given  in  addition.  Locally,  begin- 
ning deformity  in  the  limbs  may  be  overcome  by  daily  gentle  manip- 
ulation in  the  mildest  cases;  or  by  splinting,  or  the  use  of  gypsum 
cases  renewed  every  few  weeks  with  the  legs  in  a  corrected  position. 
The  use  of  braces,  which  is  preferable  when  the  patient  can  afford 
to  purchase  them,  usually  will  overcome  slight  deformities  within 
eighteen  months  or  two  years,  if  applied  while  the  bones  are  still  soft 
(before  the  age  of  two  years  and  a  half).  Bow-legs  show  a  greater 
tendency  to  spontaneous  cure,  and  improve  much  more  rapidly  under 
treatment  by  braces  than  do  knock-knees.  Good  types  of  braces  are 
shown  in  the  accompanying   illustrations  (Figs.  481  and  482);  the 


times  daih 
up   to  any 


Fig.     480. 


Rachitic       legs: 


knock-knee  on  right,  bow-leg  on 
left,  from  being  carried  con- 
stantly on  the  mother's  right  arm. 
Orthopaedic  Hospital. 


458 


DISEASES  OF  BONE 


modus  operandi  of  braces  is  not  to  overcome  the  deformity  forcibly, 

but  to  prevent  growth  in  other  than  the  proper  direction;  they 
require  constant  repair  and  readjustment,  and  the  surgeon  should  see 
that  they  are  in  repair  and  properly  adjusted  every  third  or  fourth 
week.     Usually  they  need  not  be  worn  at  night  in  bed. 

After  the  age  of  three  years,  and  occasionally  earlier,  very  little 
improvement  can  be  expected  from  conservative  measures,  and  an 
operation  should  be  undertaken.  Manual  correction  may  be  attempted 
by  Anzoletti's  method  (1909):  plaster  of  Paris  is  moulded  very 
accurately  to  the  extremity,  from  beyond  the  toes  well  up  to  the 
groin,  so  as  to  prevent  all  motion,  and  the  patient  is  kept  in  bed  on 
low  diet  for  four  or  five  weeks,  so  as  to  promote  bone  atrophy;  at 


Fig.  481. — Bow-leg  braces.  Pads  over 
internal  condyles  and  internal  malleoli, 
with  leather  apron  over  apex  of  de- 
formity.    Orthopaedic  Hospital. 


Fig.  482.  —  Knock-knee  braces.  Pads 
over  internal  condyles  and  internal  malleoli. 
Orthopaedic  Hospital. 


the  end  of  this  time  the  gypsum  is  removed,  and  the  softened  bones 
sometimes  may  be  bent  in  the  hands  to  the  desired  shape  without 
anesthetizing  the  patient.  Plaster  of  Paris  is  then  applied  in  an 
over-corrected  position,  and  the  patient  encouraged  to  walk  about, 
being  fed  up,  and  given  cod  liver  oil;  at  the  end  of  four  or  five  weeks 
the  bones  will  be  hard  enough  to  go  without  support.  I  have  tried 
the  method  several  times,  but  think  it  suitable  only  for  acute  cases, 
especially  those  of  bow-legs;  in  cases  of  long  duration  it  is  better 
to  resort  to  osteoclasis  or  osteotomy.  Osteoclasis,  or  breaking  the 
bone,  is  accomplished  by  use  of  the  osteoclast  (Fig.  483),  the  patient 
being  anesthetized;  the  limb  is  then  put  up  in  plaster  of  Paris  in 
over-corrected  position,  and  is  treated  as  a  fracture.     Osteotomy,  or 


RACHITIS 


459 


Fig.  483. — Hopkins's  osteoclast.    Orthopaedic  Hospital. 


Fig.  484.— Results  of  osteotomies  for  knock-knees  and  bow-legs.    Episcopal  Hospital. 


400 


DISEASES  OF  BONE 


division  of  the  bone  by  an  osteotome  (Fig.  509,  4),  which  may  be 
described  as  a  chisel  bevelled  on  both  edges,  so  as  to  cut  straight 
ahead,  is  done  through  a  minute  incision  which  divides  the  peri- 
osteum. The  osteotome  is  introduced  through  the  periosteum,  is 
turned  transversely  to  the  long  axis  of  the  limb,  and  is  driven  through 
the  bone  by  a  mallet  in  such  a  way  as  to  divide  it  transversely  all 


Fig.  485. — Skiagraphs  made  through  the  gypsum  cases,  showing  osteotomies 
for  bow-legs.     Orthopredic  Hospital. 


except  a  few  fibers  at  the  further  side ;  several  cuts  in  the  bone  (all  at 
the  same  level)  may  be  necessary,  but  they  are  all  made  through  the 
one  skin  incision,  making  practically  a  subcutaneous  operation.  The 
remaining  bone  fibers  are  then  fractured  by  hand,  the  incision  closed 
with  one  suture,  and  the  limb  is  put  up  in  plaster  of  Paris  in  an  over- 
corrected  position.    For  knock-knee  the  osteotomy  is  done  a  finger's 


OSTEOMALACIA  461 

breadth  above  the  epiphyseal  line  of  the  femur,  usually  on  the  outer 
side  of  the  bone;  for  bow -legs  it  is  done  at  the  apex  of  the  deformity, 
usually  only  the  tibia  being  divided,  the  fibula  bending  or  being 
broken  by  hand  (Fig.  485).  The  correction  of  anterior  curvature 
is  more  difficult  (Figs.  486  and  487).  The  patient  is  not  allowed  to 
walk  for  six  or  eight  weeks. 


Fig.  486. — Anterior   curvature  of  tibiae  Fig.  487. — Anterior  curvature  of  tibia? 

in  rachitis.     (See  Fig.  487.)     Orthopaedic       after  osteotomy.     Orthopaedic   Hospital. 
Hospital. 

Scurvy. — Scurvy  which  may  complicate  rachitis  or  occur  inde- 
pendently, should  be  borne  in  mind  as  a  possible  cause  of  symptoms 
of  bone  disease  in  infants.  Tenderness  of  shafts  of  long  bones,  with 
skiagraphic  evidences  of  subperiosteal  hemorrhages  (Fig.  488),  in  asso- 
ciation with  other  scorbutic  symptoms,  should  make  one  suspicious  of 
this  condition.  The  diagnosis  from  tuberculous  or  subacute  septic 
osteomyelitis  is  not  always  easy.  Constitutional  antiscorbutic  treat- 
ment is  indicated. 

Osteomalacia. — Osteomalacia,  or  softening  of  the  bones,  is  an 
affection  occurring  mostly  in  women,  often  in  those  who  have  borne 
several  children  in  rapid  succession.  It  is  believed  to  be  associated 
with  ovarian  disease.  Scarcely  ever  does  it  occur  before  puberty. 
Deformity  is  progressive  and  marked,  involving  the  pelvis,  the 
vertebral  column,  and  later  the  extremities.  "Spontaneous  fracture" 
(Fig.  489)  may  occur,  but  is  not  frequent.  The  disease  has  been 
treated  by  oophorectomy;  Schnell  (1913),  reviewing  334  cases  reported 
during  the  previous  fifteen  years,  found  only  7  recurrences  among  105 
treated  by  oophorectomy;  but  some  surgeons  (Bastianelli)  claim  that 
the  benefit  from  such  operations  has  been  due  to  the  chloroform  inha- 
lation  used    for    anesthesia;  and    they  now  induce  such  anesthesia 


462 


DISEASES  OF  BONE 


without  doing  an  operation  (W.  J.  Mayo,  1910).   According  to  Mayo, 
also,  different  [talian  observers  have  found  an  identical  and  specific 


Fig.  488. — Scurvy,  with  subperiosteal  hemorrhages  in  a  child  nine  years  of  age,  five 
or  six  weeks  after  first  symptoms  of  scurvy.     Patient  of  Dr.  Githens. 

diplococcus  in  the  periosteum  in  this  disease,  in  rachitis,  and  in  osteitis 
deformans;  when  a  culture  of  this  diplococcus  was  injected  into  rats 


Fig.  489. — Osteomalacia  (five  years'  duration)  in  a  man,  aged  seventy-eight  years. 
Confined  to  bed  for  six  months.  Fracture  of  right  femur  occurred  the  day  before  the 
photograph  was  taken,  and  death  from  asthenia  two  days  later.  Dr.  F.  W.  Sinkler's 
case.     Episcopal  Hospital. 

it  produced  rachitis  in  the  very  young  animal,  and  osteomalacia  in 
adult  rats.     The   relation   of  thyroid   and   parathyroid   diseases   to 


FIBROCYSTIC  OSTEITIS;  BONE  CYSTS 


463 


osteomalacia  is  not  clear.     The  parathyroids  are  believed  to  control 
calcium  metabolism. 

Osteitis  Deformans  (Paget's  Disease  of  the  Bones,  1876)  occurs  in 
adult  life,  patients  usually  not  applying  for  treatment  until  well 
past  forty  years  of  age.  It  runs  a  very  chronic  course,  lasting  many 
years,  and  growing  progressively  worse,  though  intermissions  and 
exacerbations  may  occur.  It  is  characterized  in  its  earlier  stages 
by  osteoporosis,  causing  flexibility  and  deformity  of  the  bones;  but 
later  the  bones  hypertrophy  and  become 
markedly  thickened.  Fracture  is  rare.  The 
lower  extremities  are  affected  earliest,  re- 
sulting in  general  outward  and  anterior 
bowing  of  the  knees  and  legs;  the  spine 
shows  a  long,  rounded  kyphosis,  and  the 
calvaria  becomes  very  much  thickened.  At 
times  the  bones  are  very  painful,  but  often 
progressive  enlargement  of  the  head  is  what 
first  calls  the  patient's  attention  to  his  condi- 
tion. Eventually  loss  of  height  is  observed, 
the  attitude  resembling  that  of  anthropoid 
apes,  with  bowed  head,  disproportionately 
long  arms,  and  a  waddling  gait  (Fig.  490). 
Some  weakness  and  stiffness  usually  exist, 
but  death  occurs  only  from  intercurrent  dis- 
ease, usually  pulmonary,  or  from  advanced 
arteriosclerosis  which  is  a  prominent  feature 
of  the  malady. 

Treatment. — Treatment  is  chiefly  hygienic 
and  dietetic.  Thymus  or  thyroid  extract 
may  be  of  value.  Pain  may  be  relieved 
by  application  of  proper  orthopedic  appa- 
ratus. 

Fibrous  Osteitis,  or  von  Recklinghausen's 
Disease  of  the  Bones  (1891),  was  later  (1910) 
assimilated  by  him  to  Paget's  disease,  just 
described.  It  is  a  generalized  affection,  at- 
tacking many  of  the  long  bones  simulta- 
neously; may  arise  in  childhood;  is  accom- 
panied by  numerous  pathological  fractures, 
and  entails  great  deformity  (Figs.  491  and 

492).     Should  the  process  become  arrested   the  deformities  may   be 
corrected  by  operation. 

Fibrocystic  Osteitis;  Bone  Cysts. — As  already  mentioned  (p.  113), 
Barrie  (1914)  considers  this  lesion  the  result  of  attempts  at  repair  in 
cases  primarily  resembling  hemorrhagic  osteomyelitis.  The  cyst 
usually  is  single,  and  contains  thin,  dark  brown  fluid,  never  distinctly 
hemorrhagic,  and  never  under  great  tension;  there  usually  is  a  distinct 
fibrous  lining  inside  the  bony  shell,  and   even  when  this  is  absent 


Fig.  490.— Osteitis  defor- 
mans (Paget's  disease)  in  a 
patient,  ,  aged  seventy-two 
years.  •  Duration  twelve 
years.   Orthopaedic  Hospital. 


If,  I  DISEASES  OF  BONE 

evidences  of  fibrous  osteitis   can  be   found   microscopically.     Unless 
the  cysts  are  huge  and  of  very  long  duration,  or  "there  has  been  a 


Fig.  491. Diffuse  fibrocystic  osteitis  in  a  lad  aged  seventeen.     Onset  from  five  to 

seven  years  of  age.     First  fracture  at  nine  years.     Since  then  seven  fractures.     Ortho- 
paedic Hospital. 


Fig.  492.— Same  case  as  Figs.  491  and  493.  Multiple  osteotomies  and  resections 
were  done  over  a  period  of  many  months  to  correct  deformities.  Death  from  shock 
after  last  operation. 

pathological  fracture  (Fig.  494)  there  is  no  alteration  in  the  over- 
lying periosteum.    Small  islets  of   cartilage  may  exist  in  the   cyst 


FIBROCYSTIC  OSTEITIS;  BONE  CYSTS 


465 


Fig.  493. 


-Fibrocystic  osteitis.     Section  removed  from  right  femur  of  patient  shown  in 
Figs.  491  and  492  Natural  size.     Orthopaedic  Hospital. 


Fig.  494. — Bone  cyst  of  humerus,  duration  fifteen  months;  recent  fracture  from  slight 
injury.    Cured  by  evacuation  and  scraping;  and  crushing  in  the  thin  wall  of  the  cyst 
to  obliterate  the  cavity.    Episcopal  Hospital. 
30 


166  DISEASES  OF  BONE 

wall,  and  a  few  giant  cells  may  be  present;  but  neither  occurs  in 
sufficient  amount  to  render  likely  confusion  with  degenerated  chon- 
dromas.    It   occurs  in  children,  affects  oftenest  the  humerus,  femur, 

and  tibia,  and  begins  insidiously;  in  very  many  cases  spontaneous 
fracture  or  the  deformity  resulting  from  such  an  unrecognized  fracture 
is  what  first  calls  attention  to  the  condition.  There  may  be  pain  and 
increase  in  size  of  the  bone,  but  the  disease  usually  is  easily  distinguished 
from  malignant  neoplasms  of  bone  by  the  long  duration  of  symptoms. 
Unless  the  patient  is  seen  for  fracture,  the  swelling  and  pain,  neither 
very  marked,  usually  exist  for  a  year  or  more  before  the  surgeon  is 
consulted.  Routine  examination  by  skiagraphy  may  detect  cystic 
changes  of  slight  degree  in  many  bones  not  suspected  of  being  diseased. 
The  diagnosis  from  other  forms  of  cyst  (degenerated  chondromas, 
echinococcus  disease,  etc.),  which  are  rare,  is  not  very  important 
clinically,  as  the  same  treatment  is  required.  In  bone  abscess  there 
usually  is  a  history  of  previous  osteomyelitis,  and  the  .r-ray  shows  the 
abscess  surrounded  by  sclerosed  bone.  From  myeloma,  except  in  cases 
of  very  short  duration,  distinction  usually  may  be  made  by  study  of 
skiagraphs;  myeloma  expands  the  bone  rather  abruptly,  may  cause 
periosteal  proliferation,  does  not  extend  far  up  or  down  the  medul- 
lary cavity,  sometimes  shows  trabecule,  and  at  operation  no  fibrous 
lining  is  found  beneath  the  cortex;  the  benign  bone  cyst  causes  little 
expansion  of  bone,  extends  for  some  distance  up  and  down  the 
medulla,  and  usually  a  faint,  fibrous  lining  can  be  detected.  Mye- 
loma occurs  in  young  adults  past  eighteen  years  of  age;  and  sponta- 
neous fracture  is  rare.  Bone  cysts  occur  mostly  in  children,  and 
spontaneous  fracture  is  frequent.  Subperiosteal  hematoma  may 
resemble  a  bone  cyst  if  encapsulated  by  new-formed  subperiosteal 
bone.  The  cortex  may  be  slightly  eroded,  but  the  medulla  never  is 
involved.  Such  cysts  are  not  uncommon  in  the  cranial  bones  of 
infants,  from  obstetrical  injury,  but  may  arise  elsewhere  from  con- 
tusion of  bone 

Treatment. — This  is  the  same  as  for  myeloma  (p.  114.) 
Hypertrophy  of  Bone. — This  may  be  compensatory,  as  when  one  of 
two  parallel  bones  is  removed  for  disease,  the  other  may  become  hyper- 
trophied.  Or  it  may  be  the  result  of  chronic  irritation,  as  in  thick- 
ening of  a  tibia  underlying  an  old  leg  ulcer.  Increase  in  thickness 
and  weight  is  commoner  than  increase  in  length,  though  the  latter 
occurs  to  a  marked  degree  in  some  amputation  stumps  (p.  221); 
sometimes,  too,  after  fracture  or  tuberculous  or  inflammatory  lesion  of 
bone,  actual  increase  in  length  may  occur,  or  at  least  the  affected 
bone  may  grow  faster  than  the  corresponding  bone  on  the  other 
side  of  the  body. 

Leontiasis  Ossea  (Virchow,  1865)  is  a  disease  usually  arising 
in  youth,  characterized  by  hypertrophy  of  the  face  bones,  giving 
the  face  a  leonine  expression,  due  to  the  gradual  obliteration  of  its 
features.  The  foramina  in  the  base  of  the  skull  may  be  narrowed, 
causing  exophthalmos,  blindness,  and  paralysis  of  the  various  cranial 


INFECTIONS  OF  BONE 


467 


nerves.     Hypertrophy  of  the  calvaria  causes  pressure  on  the  brain, 
with  headaches,  convulsions,  etc.    No  treatment  is  of  avail. 

Acromegaly  (P.  Marie,  1886)  is  a  disease  of  youth  or  early  adult 
life,  characterized  by  hypertrophy,  enlargement  and  thickening  of 
the  apices  and  extremities  of  the  skeleton — 
fingers,  toes,  chin,  nose,  etc. ;  while  similar  soft 
tissues  also  may  enlarge — lips,  tongue,  ears, 
and  even  penis  and  clitoris.  Increase  in  size  of 
the  jaws  results  in  abnormal  spacing  between 
the  teeth.  A  rounded  kyphos  develops  in  the 
dorsal  spine  (Fig.  495).  Headache  is  the  chief 
subjective  symptom.  The  disease  may  be  of 
long  duration  and  usually  is  caused  by  neoplas- 
tic changes  in  the  hypophysis  cerebri;  a  skia- 
graph may  demonstrate  enlargement  of  the  sella 
turcica,  and  pressure  symptoms  from  hypophy- 
seal growth  may  develop  later.  Treatment  by 
pineal,  thyroid,  thymus,  or  other  extracts  may 
be  tried,  but  the  only  hope  of  cure  consists  in 
operation  on  the  hypophysis  (see  p.  631). 

INFECTIONS  OF  BONE. 

Infection  of  a  bone  usually  occurs  through 
the  blood-stream,  some  locus  minoris  resistentice, 
generally  due  to  injury,  determining  localization 
of  the  infection.  Those  who  have  a  general 
blood-infection  (furunculosis,  typhoid  fever, 
syphilis,  tuberculosis,  etc.),  therefore,  are  pre- 
disposed to  bone  infection.  Infection  of  bone 
also  occurs  in  compound  fractures,  but  as  in 
these  the  products  of  inflammation  are  readily 
discharged  from  the  broken  surfaces  and  through 
the  wound  of  the  soft  parts,  the  disease  seldom 
assumes  such  serious  proportions  as  when  in- 
fection arises  in  the  unbroken  bone;  in  the 
latter  instance  the  very  structure  of  the  bone 
prevents  swelling,  so  that  strangulation  and 
necrosis  occur  very  early. 

Acute  Periosteitis. — Acute  periosteitis  rarely  occurs  as  an  isolated 
affection;  in  almost  every  case  there  are  also  osteitis  and  osteomye- 
litis, and  it  is  probable  that  the  infection  is  localized  first  in  the 
medulla,  and  is  propagated  to  the  periosteal  surface  of  the  bone 
through  the  Haversian  canals.  In  convalescence  from  typhoid  fever, 
however,  subperiosteal  abscess  may  occur,  and  in  most  such  cases 
there  is  no  appreciable  involvement  of  the  medulla,  and  at  most 
only  a  superficial  caries  of  the  cortex.  The  lesion  occurs  oftenest  in 
the  long  bones  and  the  ribs;  relief  of  symptoms  (pain,  tenderness, 
swelling,  fever,  etc.),  and  rapid  cure  usually  follow  incision  of  the 
periosteum  and  scraping  the  carious  bone  (Fig.  496). 


Fig.  495.  —  Acromeg- 
aly. Dr.  Hooker's  case. 
Episcopal  Hospital. 


468 


DISK  \SKS   OF   BONE 


Chronic  Periosteitis.  —  Chronic  periosteitis  is  a  frequent  lesion, 
occurring  in  many  of  the  dystrophies  already  described,  or  as  the 
result  of  contusions  of  bone,  from  chronic  inflammation  of  overlying 
soft  tissues,  and    in    chronic   infections,     especially     syphilis     (Fig. 

518).  The  long  bones  are  most  often 
affected:  the  periosteum  is  raised 
from  the  shaft  by  the  formation  of 
new  bone,  and  the  resulting  deformity 
may  be  very  evident  on  inspection. 
Distinct  periosteal  nodes  may  form,  or 
the  thickening  may  be  diffuse.  Us- 
ually there  is  a  good  deal  of  aching, 
but  no  very  acute  pain;  the  osteocopic 
(bone-tiring)  pains  become  worse  after 
exertion  and  when  the  warmth  of  bed 
induces  hyperemia  of  the  diseased 
parts.  The  treatment  is  much  the 
same  as  for  syphilitic  periosteitis  (p. 
4S2). 

Osteitis. — Osteitis  scarcely  ever  oc- 
curs as  a  recognizable  affection  apart 
from  accompanying  osteomyelitis. 

Osteomyelitis.  —  This  is  an  acute 
septic  infection  of  bone  marrow,  usu- 
ally due  to  the  Staphylococcus  aureus, 
and  affecting  mostly  the  long  bones 
of  the  extremities,  especially  the  tibia, 
femur,  and  ulna,  in  their  juxta-epiphy- 
seal  portion ,  which  was  named  by  Kocher 
the  metaphysis.  It  occurs  almost  exclusively  in  children  from  six  to 
sixteen  years  of  age,  and  often  follows  slight  trauma,  or  exposure 
to  cold  and  wet,  as  in  frequent  swimming  expeditions.  Predisposing 
causes  are  malnutrition,  convalescence  from  the  exanthemata  or  other 
general  infections. 

Owing  to  the  dense  bony  case  in  which  the  inflammation  occurs, 
it  is  extremely  rare  for  an  abscess  to  form;  instead  a  true  phlegmon 
of  bone  results,  infection  spreading  up  and  down  the  medulla.  The 
cortex  is  affected  secondarily,  and  in  most  cases  periosteitis  results 
from  transmission  of  infection  through  the  Haversian  and  Volkmann's 
canals.  The  process  rarely  extends  into  the  joints,  even  in  adults, 
and  in  children  nearly  invariably  is  arrested  at  the  cartilage  of  the 
epiphyses.  Swelling  being  impossible,  the  medullary  tissues  become 
strangulated,  and  death  of  the  bone  in  large  masses  follows  (necrosis), 
its  extent  depending  on  the  destruction  of  the  marrow  cells  within, 
and  on  the  amount  of  separation  of  periosteum  on  the  surface.  Some- 
times the  entire  shaft  of  the  bone  becomes  necrotic,  is  spontaneously 
detached  at  its  epiphyses,  and  floats  in  pus  beneath  the  unruptured 
periosteum.    Usually,  however,  before  this  stage  is  reached,  drainage 


Fig.  496.  —  Periosteitis  of  left 
tibia  nine  months  after  typhoid 
fever.  Age  nine  years.  Episcopal 
Hospital. 


OSTEOMYELITIS 


469 


is  instituted  by  operation,  or  the  periosteum  is  perforated  by  the 
pus  with  formation  of  a  parosteal  abscess  in  the  soft  tissues.  The 
periosteum  is  raised  from  the  cortex,  and  new  subperiosteal  bone  is 
formed;  this  at  first  is  plastic  but  later  becomes  sclerotic  and  is  known 
as  the  involucrum;  and  such  portions  of  the  bone  marrow  as  survive 
form  new  bone  within,  so  that  eventually  the  necrotic  portion  of 
bone,  known  as  a  sequestrum,  is  more  or  less  completely  surrounded 
by  new-formed  bone  but  still  communicates  with  the  surface  through 


r>t. 


* 


*  i 


</,-"* 


m 


■**? 


nm 


Fig.  497. — Diagram  of  changes  occurring  in  a  case  of  acute  osteomyelitis  of  the  tibia. 
In  the  first  figure,  there  is  diffuse  suppuration  in  the  medulla  of  the  diaphysis.  In 
the  second  figure,  the  products  of  inflammation  are  seen,  filling  the  space  between  the 
cortex  and  the  periosteum.  In  the  third  figure,  new  subperiosteal  bone  has  been  formed, 
and  within  this  involucrum  is  seen  a  large  sequestrum,  surrounded  by  pus,  which  dis- 
charges through  openings  in  the  involucrum,  known  as  cloacae.  In  the  fourth  figure, 
only  a  small  cortical  sequestrum  remains,  the  involucrum  has  become  very  dense,  and 
the  medullary  cavity  is  replaced  by  eburnated  bone,     (de  Quervain.) 


orifices  in  the  involucrum  known  as  cloacce,  and  through  these  a 
discharge  of  pus  continues.  Several  sequestra  may  form,  each  having 
its  own  cloaca  or  cloacae,  and  discharging  on  the  skin  surface  through 
numerous  sinuses  (Fig.  497).  When  this  stage  of  the  disease  is 
reached,  it  assumes  a  chronic  form  usually  described  by  the  term 
Necrosis  (p.  474). 

Symptoms. — These  are  both  general  and  local,  the  former  often 
so  over-shadowing  the  latter  that  without  attention  to  the  history 


470  DISEASES  OF  BONE 

and  careful  physical  examination  the  disease  has  been  mistaken  for 
toxemia  resulting  from  typhoid  fever,  pneumonia,  meningitis,  etc. 
The  disease  may  be  ushered  in  by  a  chill,  with  sudden  rise  in  tempera- 
ture to  105°  F.  or  higher,  the  child  appearing  very  ill  and  making 
little  complaint  of  the  extremity  affected.  In  these  hyperacute  cases 
death  from  septicemia  may  occur  within  a  day  or  two  in  spite  of 
active  treatment.  In  most  cases,  however,  the  affected  limb  becomes 
painful,  helpless,  and  swollen;  redness  may  not  be  evident.  Tender- 
ness is  extreme,  extending  throughout  the  shaft  of  the  affected  bone, 
but  most  intense  at  one  spot.  Indeed,  tenderness  usually  is  so  great 
as  absolutely  to  prevent  palpation  at  the  seat  of  greatest  disease. 
Even  if  the  remainder  of  the  shaft  be  not  tender  to  palpation  or 
tapping,  prolonged  gentle  pressure  even  at  a  distance  will  eventually 
and  suddenly  become  acutely  painful;  this  is  a  valuable  diagnostic 
point  (Nichols,  1907).  The  disease  is  often  mistaken  for  acute  rheu- 
matic arthritis,  with  most  disastrous  results;  but  in  osteomyelitis  the 
joints  are  not  involved,  while  the  bones  are;  and  multiple  lesions, 
common  in  acute  rheumatic  fever,  are  rare  so  early  in  the  course  of 
osteomyelitis,  though  quite  frequent  later.  The  distinction  between 
deep-seated  suppuration  of  bone,  and  serous  joint  effusion  should 
not  be  difficult  if  physical  examination  is  thorough.  The  mistake  is 
most  apt  to  occur  in  the  case  of  bones  which  are  not  subcutaneous 
(femur,  radius,  humerus),  but  ignorance  and  carelessness  may  err 
even  in  the  case  of  the  tibia  or  ulna.  At  later  stages,  if  the  patient 
survives,  edema  of  the  skin,  with  redness,  and  even  fluctuation, 
make  a  mistake  absolutely  unpardonable.  Throughout  the  course 
of  the  disease  the  surgeon  should  be  on  the  lookout  for  secondary 
invasion  of  other  bones,  which  is  often  overlooked  for  some  days, 
owing  to  a  subacute  onset. 

Treatment. — As  soon  as  the  diagnosis  is  made,  the  bone  should  be 
opened.  Delay  even  of  a  few  hours  is  dangerous  in  very  acute  cases, 
leading  to  widespread  necrosis,  pyemia,  and  multiple  secondary  foci  of 
osteomyelitis  in  other  bones.  In  a  case  of  which  I  have  cognizance, 
the  patient  was  treated  during  four  weeks  for  typhoid  fever,  with  the 
result  that  not  only  was  he  gravely  ill  for  many  months  with  pyemia, 
but  he  lost  his  entire  ulna,  and  developed  secondary  lesions  in  one 
tibia,  and  both  femora  (Fig.  498).  The  patient  should  be  anesthe- 
tized, the  limb  elevated  until  bloodless,  and  an  Esmarch  band  applied 
well  above  the  diseased  area;  a  free  incision  is  then  made  dividing 
the  periosteum  where  subcutaneous  or  after  exposure  through  the 
proper  intermuscular  space.  Sometimes  the  periosteum  is  found  more 
or  less  widely  detached  from  the  cortex  by  pus;  the  cortex  then  may 
look  white  and  dead,  but  generally  a  few  minute  bleeding-points 
(Volkmann's  canals)  may  be  seen.  If  the  periosteum  is  detached 
from  the  cortex  throughout,  and  the  shaft  is  loosened  at  its  epiphy- 
seal attachments,  the  entire  shaft  may  be  removed,  either  in  one 
piece,  or  by  wrenching  each  end  free  after  sawing  the  bone  across 
its  center;  in  the  case  of  the  femur  and  humerus,  however,  where  no 


OSTEOMYELITIS  471 

parallel  bone  exists  to  act  as  splint,  it  will  be  better,  even  under 
these  circumstances,  to  leave  the  shaft  in  place  until  an  involucrum 
has  formed  dense  enough  to  maintain  the  form  of  the  limb.  Where 
the  periosteum  is  only  partly  detached  from  the  bone,  or  where  the 
infection  has  .not  yet  extended  from  the  marrow  out  through  the 
cortex,  the  cortical  bone  may  appear  normal;  but  in  all  cases  the 
surgeon  should  open  the  medulla  to  provide  drainage.  The  periosteum 
should  be  carefully  detached  from  a  sufficient  area,  and  the  medulla 
exposed  by  trephine  or  gouge  and  mallet.  The  marrow  usually  is 
found  softened,  grayish  yellow,  or  even  purulent;  but  failure  to  find 
frank  pus  by  no  means  indicates  that  septic  osteomyelitis  is  absent. 
If  the  operation  is  done  sufficiently  early,  the  inflammation  may  not 
have  progressed  to  the  stage  of  suppuration;  and  in  certain  cases  of 
subacute  infection  (perhaps  tuberculous),  there  is  what  is  known  as 


Fig.  498. — Skiagraph  of  acute  osteomyelitis  of  femur;  age  seven  years;  treated 
at  home  for  "typhoid  fever"  for  four  weeks.     Episcopal  Hospital. 

albuminous  osteomyelitis  (Oilier,  1872),  the  exudate  being  serous  or  at 
most  sero-purulent.  In  such  cases,  or  if  the  diagnosis  is  doubtful, 
the  marrow  may  be  exposed  by  drill  holes.  If  the  medulla  is  found 
widely  infected,  a  second  button  of  bone  may  be  removed  at  a  dis- 
tance from  the  first,  to  determine  the  extent  of  medullary  implication; 
and  the  intervening  bone  may  then  be  removed  by  gouge  and  mallet, 
cutting  a  long  gutter  in  the  cortex,  and  widely  exposing  the  medulla. 
It  never  is  proper  to  curette  the  marrow  or  attempt  its  removal  in 
any  way,  any  more  than  it  is  proper  to  curette  an  acute  phlegmon  of 
the  soft  parts  (p.  50);  it  is  probable  that  all  the  marrow  cells  are 
not  destroyed,  and  such  as  still  are  living  are  very  important  agents 
in  forming  new  cortical  bone.  The  periosteum  alone  is  not  always 
capable  of  forming  an  entire  new  shaft.  In  exceptional  cases  total 
resection  of  the  diaphysis,  even  if  this  is  not  wholly  necrotic,  may 


172 


DISEASES  OF  BONE 


be  done   when   a    parallel  bone  exists  to  act  as  splint,  it'  the  osteo- 
myelitis is  so  widespread  as  to  render  probable  total  necrosis  later, 

or  if  the  patient's  condition  is  so  sep- 
tic that  prompt  convalescence  is  de- 
manded (Fig.  40!));  but  such  removal 
often  leaves  a  deformed  (Fig.  500)  or 
helpless  limb  (Fig.  501),  which  later 
may  require  another  operation  (p. 
248).  In  the  case  of  the  humerus 
and  femur,  where  the  disease  is  not 
very  acute,  it  is  sufficient  to  trephine 
the  bone  at  the  limits  of  inflammation, 
and  pass  a  drainage  tube  from  one 
opening  to  the  other  through  the 
medulla.  If  guttering  has  been  done, 
the  marrow  cavity  is  firmly  packed 
with  iodoform  gauze,  the  wound  is 
left  widely  open,  and  is  allowed  to 
heal  by  granulation  (Fig.  502).  If 
the  entire  diaphysis  has  been  removed, 
the  same  course  may  be  pursued,  or 


Fig.  499. — Specimen  of  tibia  ex- 
cised for  osteomyelitis ;  below  is  seen 
the  trephine  opening  made  for  ex- 
ploration; above,  the  large  opening 
made  by  gouge  and  mallet.  Finally 
the  entire  diaphysis  was  excised. 
Episcopal  Hospital. 


Fig.  500. — Deformity  following  excision  of 
radius  twenty-five  years  ago  for  osteomyelitis; 
useful  hand ;  man  works  as  laborer.  Episcopal 
Hospital. 


Fig.  501. — Deformity  from  excision  of  tibia  for  osteomyelitis.  Operation  two  years 
ago.  Now  fourteen  years  old.  Ankylosis  of  knee.  Only  upper  and  lower  epiphyses  of 
tibia  remain,  with  about  three  inches  of  shaft  above  malleolus.  Cannot  stand  on  leg. 
Episcopal  Hospital. 


OSTEOMYELITIS 


473 


the  periosteum   may  be   sutured    lightly  together,   obliterating    the 
cavity,  as  advised  by  Nichols  (1904). 


Fig.  502. — Granulating  wound  two  months  after  guttering  (evidement)  of  tibia 
for  osteomyelitis.     Children's  Hospital. 


If  operation  has  been  done  early 
enough,  necrosis  of  the  shaft  may  not 
occur,  and  permanent  healing  will  follow 
the  primary  intervention.  In  most  cases, 
however,  portions  of  the  cortex  become 
necrotic,  are  exfoliated  as  sequestra, 
and  may  require  subsequent  operation 
for  their  removal. 

Chronic  Osteomyelitis. — This  is  rarer 
than  the  acute  form  of  the  disease  and 
is  due  to  a  less  virulent  infection.  The 
bone  is  infiltrated  with  purulent  mate- 
rial, its  lime-salts  are  more  or  less  ab- 
sorbed and  the  marrow  cavity  obliter- 
ated. Treatment. — Free  drainage  should 
be  provided,  and,  if  possible,  all  the  dis- 
eased   bone    should   be    gouged  away. 


,sW-A 


*'A  ,% 


Fig.  503. — Cortical  sequestra  following  osteo- 
myelitis of  femur.     Episcopal  Hospital. 


Fig.  504. — Necrosis  of  hum- 
erus, showing  tubular  sequestrum, 
involucrum,  and  cloacae.  Os- 
teoporosis above.  Episcopal  Hos- 
pital. 


474 


DISEASES  OF  BONE 


Recurrences  arc  frequent   unless  radical  operation  is  done.     Even- 
tually hypertrophy,  sclerosis,  and  eburnation  occur. 


Fig.  505. — Skiagraph  of  necrosis  of  tibia,  showing  large  sequestrum  within 
involucrum.     Episcopal  Hospital. 


Fig.  506. — Sequestrum  of  radius  ulcerating  out,  eleven  months  after  compound 
comminuted  fracture.     Episcopal  Hospital. 

Necrosis. — Necrosis  is  the  term  applied  to  the  chronic  stage  which 
succeeds  acute  or  subacute  osteomyelitis.  It  implies  the  presence  of 
a  sequestrum,  more  or  less  detached;  of  an  involucrum,  more  or  less 
developed;  and  of  cloacae,  usually  communicating  with  the   surface 


NECROSIS  OF  BONE 


475 


of  the  limb  by  sinuses  through  which  bare  bone  may  be  felt.  Caries 
is  that  condition  of  bone  comparable  to  an  ulcer  of  the  soft  parts,  there 
being  no  actual  sequestrum  (slough),  but  only  death  of  bone  in 
molecular  masses.  It  occurs  chiefly  in  tuberculous  bone  disease 
(p.  479).  A  sequestrum  may  be  due  to  necrosis  of  the  superficial 
cortical  layers  (Fig.  503),  or  there  may  be  a  total  or  "tubular"  seques- 
trum (Fig.  504).  The  subperiosteal  bone  is  soft  and  plastic  when 
newly  formed,  and  possesses  great  powers  of  regeneration;  if,  how- 
ever, a  sequestrum  remains  beneath  it  long  enough,  the  involucrum 
gradually  loses  its  regenerative  powers,  and  becomes  dense  and 
sclerosed;  sometimes  so  dense  that  the  finest  steel  makes  no  impres- 
sion on  it.  Therefore,  it  is  better,  whenever  possible,  to  remove 
sequestra  while  the  involucrum  is  still  plastic,  so  that  the  cavity 
left  will  be  filled  up  promptly  by  periosteal  proliferation.  This  stage 
usually  ceases  about  two  or  three  months  after  the  primary  infection. 
The  plastic  condition  of  the  subperiosteal  bone  may  be  determined 
by  sticking  a  needle  through  it,  close  to  a  sinus,  when  crackling 
will  occur,  and  the  needle  will  be 
arrested  by  the  necrotic  shaft  under- 
neath ;  or  it  may  be  possible  to  see  the 
new-formed  bone  in  a  skiagraph  (Fig. 
505).  If  there  is  a  parallel  bone  pres- 
ent, as  in  the  forearm  and  leg,  removal 
of  the  sequestra  may  be  undertaken  as 
soon  as  the  patient  convalesces  from 
the  first  operation,  and  prompt  regen- 
eration even  of  an  entire  shaft  may 
be  anticipated;  but  when  the  femur 
or  humerus  is  affected,  it  is  better  to 
delay  secondary  operation  until  a  fairly 
strong  involucrum  has  formed.  This  is 
about  two  or  three  months  after  the 
onset  of  the  disease;  the  strength  of 
the  involucrum  may  be  determined  by 
skiagraphy,  and  its  total  thickness  should 
approximate  half  that  of  the  normal 
bone.  In  some  cases  sequestra  will 
work  themselves  loose,  and  eventually 
may  be  discharged  spontaneously  (Figs. 
506  and  507),  but  this  may  require 
many  years,  and  in  most  cases  ulti- 
mate cure  is  much  accelerated  by 
operation. 

Sequestrotomy,  as  the  operation  for 
the  removal  of  sequestra  is  called,  is 
done  under  Esmarch  anemia :  a  rubber 
bandage  is  applied  from  the  fingers  or  toes  to  above  the  upper  limit 
of  disease  (Fig.  508),  thus  removing  most  of  the  blood  from  the  limb; 


Fig.  507. — Chronic  osteomyelitis 
of  femur;  age  forty-three  years,  onset 
seven  years  ago.  No  symptoms  for 
several  years  until  a  few  weeks  ago, 
when  a  sequestrum  began  to  work 
loose;  sequestrum  extracted  through 
sinus,  which  promptly  healed.  Epis- 
copal Hospital. 


470 


DISEASES  OF  BONE 


an  Esmarchband  is  then  applied  just  above  the  termination  of  the 
elastic  bandage,  which  is  then  removed,  leaving  a  bloodless  field  for 

operation.  This  is  im- 
portant because  hem- 
orrhage from  the  in- 
volucrum  and  medulla 
may  be  free,  and,  unless 
the  wound  is  dry,  it  is 
difficult  to  distinguish 
dead  from  living  bone. 
The  limb  is  then   in- 

Fig.  508.— Rubber  bandage  applied  for  bloodless  opera-  •       i         i  nf-l l lrl  ino-        as 

tion.  The  Esmarrh  band  is  then  applied  above  the  knee,  USCU,        liiLiuunig        ao 

and   the   rubber  bandage  is  removed   from  the  leg,  ex-  many   SlUUSeS  as  pOSSl- 

ppsing  the  seat  of  operation  (sequestrotomy  of  tibia).  ^      .         he    ^        ^    m_ 
I'.piscopal  Hospital. 


Fig.  509.— Instruments  for  operation  on  bones:  1,  wooden  mallet;  2,  Hey  s  saw;  3, 
chisel;  4,  osteotome;  5,  Volkmann's  sharp  spoon  or  bone  curette;  6,  Jones  s  gouge;  7, 
gouge  bevelled  on  its  convexity;  8,  thumb  gouge;  9,  gouge  forceps;  10,  11,  sequestrum 
forceps;  12,  burr  or  osteotrite. 


NECROSIS  OF  BONE 


477 


cision,  or  excising  the  scar  of  previous  operation.  If  the  subperios- 
teal bone  is  still  plastic,  it  is  incised  with  a  heavy  knife  and  carefully 
reflected  from  the  underlying  necrotic  shaft,  which  is  then  removed 
piecemeal  or  in  mass.  If  a  dense  involucrum  is  present,  it  is  searched 
for  cloaca?,  and  the  location  of  sequestra  determined,  enough  of  the 


Fig.  510. — Skiagraph  showing  involucrum 
of  ulna,  after  removal  of  sequestra.  Note 
numerous  cloaca?.  Age  fourteen  years.  Epis- 
copal Hospital. 


Fig.  511.  —  Iodoform  bone-wax  in 
cavity  of  tibia  (plombage) .  Complete 
healing  secured  without  further  oper- 
ation.    Episcopal  Hospital. 


overlying  bone  being  removed  to  permit  of  their  removal;  they  are 
more  apt  to  be  completely  detached  from  surrounding  healthy  bone 
than  at  an  earlier  stage.  When  the  sequestrum  is  not  completely 
detached,  suspected  bone  should  be  removed  by  gouge  and  mallet 
until   healthy   bone    is   reached.     This  is   known    by   the   fact  that 


178 


DISEASES  OF  BONE 


minute  blood  spots  on  the  bone  (Haversian  eanals)  cannot  be  washed 
away  in  living  bone,  whereas  rinsing  a  chip  of  dead  bone  in  water 
will  remove  all  blood  from  its  surface. 

If  the  operation  is  done  before  sclerosis  of  the  involucrum  the  cavity, 
if  small,  may  be  allowed  to  fill  with  blood-clot,  and  this  probably 
will  be  converted  into  bony  tissue  by  subperiosteal  proliferation 
(Fig.  510).  When,  however,  the  involucrum  is  dense,  any  cavity  left 
will  remain  a  cavity,  unless  filled  with  some  substance  to  stimulate 
ossification.  Probably  the  best  substance  for  such  purposes  is  the 
iodoform  bone  wax  of  Mosetig-Moorhof  (1903):  iodoform,  60  parts; 
spermaceti  and  oil  of  sesame,  each  40  parts.  This  is  heated  to  80°  C. 
while  being  mixed,  and  again  heated  to  00°  C.  before  being  poured 
into  the  bone  cavity.  Such  an  operation  is  termed  plombage  (Fig. 
511).  I  have  used  as  much  as  100  grams  of  this  wax  at  one  time 
(in  a  girl  of  seventeen  years),  but  others  have  reported  symptoms 


Fig.  512. — -Acute  osteomyelitis  of  left  humerus, 
upper  end;  age  eight  months.  Admitted  with  diag- 
nosis of  scurvy.  Temperature  rose  to  105°  F., 
and  at  operation  epiphysis  was  found  separated. 
Recovery.     Children's  Hospital. 


Fig.  513. — Diagram  showing 
the  relation  of  the  upper  epiphysis 
of  the  humerus  to  the  shoulder- 
joint. 


of  iodoform  poisoning  from  less  quantities.  The  best  results  follow 
when  the  cavity  is  dried  and  sterilized  by  a  hot  air  blast  before  pouring 
in  the  wrax;  or  by  the  actual  cautery,  taking  care  only  to  sear  and 
not  to  char  the  bone.  If  this  cannot  be  done,  the  cavity  may  be 
swabbed  out  with  formalin  and  dried  with  sterile  gauze.  In  these 
chronic  cases  there  is  only  an  attenuated  infection.  The  soft  tissues 
are  sutured  tight  over  the  wax  as  it  cools,  no  drainage  being  employed; 
and  though  some  of  the  wax  may  be  discharged  eventually  through  a 
sinus,  convalescence  is  much  less  tedious  than  if  no  bone  filling  had 
been  employed.  Beck's  bismuth  paste  (p.  527)  may  be  employed  in 
small  quantities  instead  of  iodoform  bone  wax,  but  is  less  suitable. 
In  cases  where  the  cavity  left  is  exceedingly  large,  it  is  better  to  resort 
to  the  old  operation  of  evidement,  in  which  the  entire  anterior  and  most 
of  the  lateral  walls  of  the  involucrum  are  removed  by  gouge  and 
mallet,  so  that  only  a  superficial  trough  remains  representing  the 
posterior  wall  of  the  involucrum,  thus  allowing  the  soft  parts  to  grow 


TUBERCULOSIS  OF  BONE  479 

down  and  across  the  cavity  (Fig.  502),  which  is  packed  with  gauze. 
Though  healing  may  take  a  year  or  more,  the  cure  eventually  is  com- 
plete. If  the  cavity  can  be  sterilized  after  such  mechanical  preparation, 
the  soft  parts  may  be  replaced  at  once,  or  as  soon  as  its  sterility  is 
ascertained.  Neuber  (1896)  tried  to  hasten  recovery  by  nailing  flaps 
of  soft  tissues  in  the  gutter  left  by  eiidement  and  in  more  recent  times 
pedicled  flaps  of  muscle  have  been  implanted,  or  even  free  transplants 
of  fat. 

Osteomyelitis  in  Infancy.1 — Here  certain  special  features  require 
separate  mention.  The  condition  frequently  is  overlooked,  from  neglect 
of  physical  examination;  and  the  closeness  of  a  lesion  to  a  joint  (the 
shoulder  and  hip  are  especially  liable  to  the  disease)  may  render  it 
likely  to  be  confused  with  acute  rheumatic  arthritis  or  joint-injury; 
indeed,  as  the  epiphysis  becomes  detached  from  the  shaft  quite  early 
in  the  disease,  the  resemblance  to  fracture  is  considerable.  Infection 
of  the  joint  is  frequent,  owing  to  the  position  of  the  epiphyseal  line 
which  even  at  the  shoulder  is  partly  intra-articular  (Fig.  513),  thus 
affording  scarcely  any  chance  for  extra-articular  drainage.  When  the 
pus  has  perforated  the  capsule,  making  beneath  the  muscles  a  tense, 
hot,  painful  swelling,  with  enlarged  veins,  a  diagnosis  of  sarcoma  often 
has  been  made. 

Treatment. — Treatment  consists  in  early  incision,  exposing  the 
septic  focus  with  curette,  and  draining  the  cavity  with  gauze.  If 
pyarthrosis  develops,  the  joint  also  should  be  drained;  and  the  epi- 
physis, if  completely  detached,  should  be  removed.  Deformity  from 
interference  with  growth,  flail-joint,  or  pathological  luxation  (especially 
at  the  hip)  may  follow.    Ankylosis  is  rare. 

Bone  Abscess. — As  a  result  of  osteomyelitis  a  residual  abscess 
(p.  856)  may  form  in  bone,  most  frequently  in  the  tibia  (Brodie's 
abscess,  1824).  Very  rarely  such  an  abscess  may  be  the  primary 
lesion,  no  diffuse  osteomyelitis  having  preceded  it;  such  cases  usually 
are  tuberculous.  A  bone  abscess  is  confined  by  a  dense  wall  of 
sclerosed  bone,  and  may  remain  latent  for  many  years,  causing 
intermittent  attacks  of  pain  and  limping,  and  being  finally  roused 
to  acute  stage  by  trauma  or  constitutional  affection. 

Diagnosis.- — The  diagnosis  depends  on  the  history,  persistent  local- 
ized bone  tenderness,  and  .r-ray  examination. 

Treatment. — The  dense  wall  should  be  cut  away,  the  pus  evacuated, 
the  cavity  sterilized,  and  treated  as  other  bone  cavities  (p.  478).  If 
the  abscess  is  small,  and  if  its  outlines  can  be  well  defined  by  .r-ray 
examination,  it  may  be  possible  to  excise  it  in  one  mass,  by  cutting 
through  healthy  bone  on  all  sides. 

Tuberculosis  of  Bone. — Tuberculosis  rarely  affects  the  diaphyses 
of  long  bones,  its  lesions  being  confined  almost  exclusively  to  the 
region  of  the  epiphyseal  cartilages;  but  in  short  bones  (hands,  feet, 
vertebra?),  diffuse  medullary  involvement  is  common.  There  are 
good  anatomical  reasons  for  this.    As  noted  in  Chapter  III,  tubercle 

1  The  disease  has  long  been  known  as  acute  epiphysitis,  or  acute  arthritis  of  infants 
(T.  Smith,  1874). 


480  DISEASES  OF  BONE 

bacilli  usually  find  lodgement  in  the  lymph  nodes,  and  only  when 
these  caseate  and  rupture  do  the  bacilli  escape  into  the  blood-stream. 
Infection  of  bone,  therefore,  occurs  through  the  blood,  the  lesion 
being  an  infarct  or  embolus  which  has  successfully  passed  through 
the  pulmonary  capillaries.  There  are  three  sets  of  arteries  supplying 
long  bones — one,  the  main  nutrient  artery,  enters  the  diaphysis, 
and  branches  in  both  directions;  a  second  enters  the  metaphysis, 
while  the  epiphyseal  arteries  form  the  third  group;  now  all  these 
arteries  send  their  terminal  branches  to  the  region  of  the  epiphyseal 
cartilage  (which  is  bloodless),  and  they  do  not  inosculate  with  each 
other.  It  is  in  this  region,  therefore,  that  bacterial  emboli  lodge, 
no  matter  by  which  of  the  three  arterial  systems  they  enter  the 
bone.  In  short  bones,  however,  the  main  nutrient  artery  breaks 
up  into  small  branches  almost  as  soon  as  it  enters  the  cortex,  and 
tuberculous  emboli  are  arrested  in  the  medulla.  It  is  denied  by  some 
that  trauma,  in  creating  a  locus  minoris  resistentioe,  has  any  influence 
in  determining  the  localization  of  tuberculous  foci  in  bone;  but  clinic- 
ally it  is  a  well  established  fact  that  any  site  of  lessened  resistance 
is  prone  to  invasion  by  tuberculosis,  whether  the  primary  change  is 
traumatic  or  infectious.  According  to  Ely  (1911)  the  reason  that 
tuberculosis  develops  in  the  neighborhood  of  the  epiphyses,  and  not 
in  other  regions  (as  the  brain)  which  are  supplied  by  end-arteries,  is 
because  in  the  epiphyses  the  soil  is  suitable  for  the  growth  of  tubercle 
bacilli,  while  elsewhere  it  is  not  (see  p.  519).  If  the  tuberculous 
process  begins  on  the  shaft  side  of  the  epiphyseal  cartilage  of  a  long 
bone  (i.  e.,  in  the  metaphysis),  the  resulting  lesion  resembles  a  very 
subacute  type  of  septic  osteomyelitis;  this  condition  appears  to  be 
more  common  in  Great  Britain  and  on  the  continent  of  Europe  than 
in  this  country.  Its  existence  was  recognized  by  Volkmann  in  1879, 
and  Stiles  (1912)  called  renewed  attention  to  it.  If,  however,  the  tuber- 
culous embolus  lodges  on  the  joint  side  of  the  epiphyseal  cartilage  the 
joint  is  quickly  invaded;  and  this  often  occurs  even  when  the  meta- 
physis is  first  involved,  especially  in  joints  where  the  epiphyseal  car- 
tilage is  largely  inside  the  joint  capsule. 

The  affected  area  undergoes  caseation,  the  bony  framework  melting 
away  in  the  center,  while  proliferation  may  take  place  under  the 
periosteum.  In  favorable  cases  the  disease  may  become  latent, 
by  encapsulation  of  the  tuberculous  focus;  or  softening  may  extend, 
the  cold  abscess  may  rupture  into  a  neighboring  joint  (very  frequent 
in  case  of  long  bones),  may  work  its  way  to  the  skin  surface  through 
a  sinuous  tract,  or  may  cause  gradual  expansion  of  the  cortex,  with- 
out rupture  (especially  in  the  phalanges).  Thus  a  tuberculous  bone 
cyst  may  develop.  Secondary  pyogenic  infection  may  occur  espe- 
cially after  sinus  formation,  and  an  osteomyelitis  originally  purely 
pyogenic  may  become  secondarily  infected  by  tuberculosis.  For  such 
cases  more  or  less  formal  operation  (sequestrotomy,  plombage,  evide- 
ment)  may  be  required.  Joint  infection  is  so  very  frequent  in  the  case 
of  long  bones  (especially  the  femur,  tibia,  and  humerus)  that  it  is  best 
to  study  epiphyseal  tuberculosis  in  connection  with  tuberculosis  of 


TUBERCULOSIS  OF  BONE 


481 


joints  (p.  519).    This  is  also  the  case  in  the  bones  of  the  carpus  and 
tarsus.    Vertebral  tuberculosis  is  considered  in  Chapter  XVIII. 

In  the  metacarpal  bones  and  phalanges  a  diffuse  tuberculous 
osteomyelitis  follows  the  arrest  of  tuberculous  emboli,  and  the  lesions 
are  the  same  in  kind  as,  though  running 
a  much  less  acute  course  than  in  pyo- 
genic osteomyelitis.  Tuberculous  dactyl- 
itis, as  this  form  is  called,  occurs  almost 
exclusively  in  infants  and  young  children 
(Figs.  37  and  514);  it  may  affect  several 
digits,  and  may  be  accompanied  by 
tuberculous  bone  disease  elsewhere. 
Caries  of  facial  bones  in  infants  usually 
is  tuberculous.  Local  rest  and  clean- 
liness, and  general  hygienic  measures 
usually  cure  the  disease,  though  the 
finger  may  be  deformed  from  extrusion 
of  sequestra,  ankylosis,  etc. 

Caries  of  the  skull  from   tuberculosis  is  not  very  rare  in  adults 
(Fig.  515).     The  diagnosis  depends  on  the  discovery  of  tuberculosis 


Fig.  514. — Tuberculous  dactyl- 
itis, early  stage;  age  three  years; 
duration  seven  months.  Epis- 
copal Hospital. 


Fig.  515. — Tuberculous  caries  of  skull.  Age  thirty-nine  years.  Phthisis  for  eight 
or  nine  years.  Present  trouble  began  by  swelling  like  wen,  nine  months  ago.  Six 
months  ago  this  ruptured  and  has  been  moist  or  scabbed  ever  since.  Depression  in 
bone  palpable.  Has  another  area  still  in  wen  stage,  fluctuating  and  red.  Episcopal 
Hospital. 

elsewhere  in  the  body  (notably  the  lung),  on  the  exclusion  of  syphilis, 
and  on  the  chronic  and  indolent  course  of  the  affection. 
31 


482 


DISEASES  OF  BONE 


Syphilis  of  Bone. — Osseous  manifestations  of  syphilis  occur  late 
in  the  disease,  with  the  exception  of  fugacious  attacks  of  periosteitis 


Fig.  516. — Syphilitic  dactylitis.  Age  twenty-eight  years;  duration  five  months 
Five  years  after  chancre.  Pathological  fracture  of  phalanx.  (See  Fig.  517.)  Episcopal 
Hospital. 


Fig.  517. 


-Skiagraph  of  finger  shown  in  Fig  516.     (Syphilitic  dactylitis.)     Note 
pathological  fracture  of  phalanx.     Episcopal  Hospital. 


SYPHILIS  OF  BONE 


483 


in  the  secondary  stage.  The  lesions  resemble  those  occurring  in  the 
other  infectious  granulomas,  involving  softening  and  caries,  or  pro- 
liferation and  eburnation.  Both  processes  frequently  occur  at  once 
in  different  parts  of  the  same  bone. 

In  hereditary  syphilis  the  earliest  bone-lesions  are  those  in  the 
cranium  and  phalanges,  occurring  mostly  in  young  infants.  In 
the  cranium  softening,  caries,  and  suppuration  are  frequent,  with 
circumferential  periosteal  over-growth,  forming  the  so-called  Parrot's 
nodes  (1879);  or  mere  thinning  of  the  skull  from  malnutrition  and 
pressure  may  occur,  affecting  especially  the  occipital  bone.      Caries 

of  the  bony  nasal  septum  and 
palate  bones  also  is  seen. 
Syphilitic  dactylitis  is  difficult 
to  distinguish  from  tuberculous 
dactylitis,  but  usually  may  be 


Fig.  518. — Syphilitic  periosteitis  of  left 
tibia,  early  stage;  duration  three  months. 
Hereditary  syphilis,  patient  also  having 
Hutchinson  teeth  and  interstitial  kera- 
titis and  marked  genu  valgum.  Age  thir- 
teen years.  (See  also  Figs.  519,  520,  and 
521.)     Orthopaedic  Hospital. 


Fig.  519. — Same  patient  as  Fig.  518: 
Sabre-blade  tibia  (left),  from  photo- 
graph two  years  after  Fig.  518.  Note 
also  syphilitic  arthritis  of  right  knee. 
Orthopaedic  Hospital. 


recognized  by  the  family  history,  existence  of  specific  lesions  else- 
where, and  results  of  anti-syphilitic  remedies;  it  occurs  in  acquired 
as  well  as  in  congenital  syphilis  (Figs.  516  and  517).  In  tuberculous 
dactylitis  microscopical  examination  or  inoculation  may  reveal  the 
nature  of  the  process.  Constitutional  anti-syphilitic  treatment  of 
the  mother,  if  the  infant  is  nursing,  always  should  be  employed  in 
connection  with  local  treatment. 

From  one  to  six  years  of  age  there  are  few  manifestations  of  heredi- 
tary syphilis,  but  after  this  period  disease  of  the  long  bones  is 
frequent,  especially  of  the  tibiae,  one  or  both  of  which  develop  a 
periosteitis,  at  first  more  or  less  well  defined  (Fig.  518),  but  later 


484 


DISEASES  OF  BONE 


diffuse  and  producing  characteristic  "sabre-blade  deformity"  (Fig. 
~)\\)).  The  bone  may  be  softened  early  in  the  affection,  but  later 
thickening  and  elongation  occur,  and  the  bone  is  markedly  sclerosed 
(Figs.  520  and  521).  If  the  pain  does  not  yield  to  anti-syphilitic 
remedies,  the  bone  may  be  drilled  in  various  places,  thus  relieving 
tension;  while  during  the  stage  of  osteoporosis  much  comfort  may 
be  derived  from  support  by  braces.  Osteomyelitis  rarely  is  due  to 
syphilis,  but  in  children  gummatous  epiphyseal  lesions  may  occur,  and 


Fig. 520 


Fig.  521 


Figs.  520  and  521.; — Skiagraphs  of  syphilitic  periosteitis  of  tibia?,  showing  "sabre- 
blade"  deformity  with  hypertrophy  and  sclerosis  of  the  bones.  Age  nine  years. 
Episcopal  Hospital. 

cause  marked  local  over-growth  (Post,  quoted  by  Nichols,  1907);  or 
by  softening  and  invasion  of  the  joint  may  produce  tuberculous-like 
arthritis  (p.  545.) 

In  acquired  syphilis  the  chief  bony  manifestation  of  the  disease  is 
the  periosteal  gumma,  which  may  begin  with  pseudo-inflammatory 
symptoms,  and  occasionally  breaks  externally;  under  proper  anti- 
syphilitic  treatment,  however,  it  is  apt  to  be  absorbed,  leaving  a 
depressed  area  on  the  surface  of  the  bone  (calvaria,  nasal  bones, 
palate,  sternum,  tibia)   due  to  dry  caries  and    lacunar    resorption, 


TUMORS  OF  BONE 


485 


with  a  thickened  margin  due  to  periosteal 
proliferation.  If  the  process  is  arrested  be- 
fore softening  of  the  gumma  occurs,  perios- 
teal nodes  or  exostoses  may  remain  instead 
of  depression  due  to  caries.  Rarely  a  dis- 
tinct sequestrum  forms;  this  is  characteris- 
tically worm-eaten  in  appearance  and  may 
require  many  years  for  exfoliation.  In  all 
cases  where  sinus  formation  occurs,  sec- 
ondary pyogenic  infection  is  frequent,  and 
sequestrotomy,  etc.,  may  be  necessary;  in 
other  cases  constitutional  treatment  alone 
often  is  sufficient  to  relieve  symptoms  and 
arrest  the  progress  of  the  disease.  Pain- 
ful exostoses  may  be  removed,  or  eburnated 
bone  (Fig.  522)  drilled. 

TUMORS  OF  BONE. 


Fig.  522. — Syphilitic  osteitis 
causing  eburnation  of  the  tarsal 
bones.  Patient  had  a  chancre 
eighteen  years  ago,  and  has 
pulmonary  emphysema  which 
may  possibly  be  an  etiological 
factor  in  the  bone  disease. 


Here  may  be  recognized  diseases  which 
comprise   what  Adami  calls  blastomatoid 

conditions   (p.   107),   as  well    as   true  neoplasms  of  bone.     In  the 
former  category  belong,  perhaps,   certain  of  the  diseases  described 

as  dystrophies   of   bone,  as   well  as  many 
forms  of  exostosis,  hyperostosis,  etc. 

Among  the  exostoses  (p.  Ill)  several 
clinical  types  are  recognizable,  and  deserve 
short  mention  here.  They  are  divided 
into  the  cartilaginous  and  fibrous  forms. 
( 'artilaginous  exostoses  are  single  or  multiple 
out-growths  arising  from  epiphyseal  cartil- 
ages or  in  the  neighborhood  of  epiphyseal 
lines;  they  are  most  frequent  at  the  upper 
end  of  the  tibia  (Fig.  523)  or  lower  end  of 
the  femur  (Fig.  524),  and  may  cause  trouble 
by  pressure  on  structures  in  the  popliteal 
space.  Excision  is  the  proper  treatment, 
removing  also  the  portion  of  bone  from 
which  they  grow,  as  recurrence  is  frequent. 
One  typical  affection,  usually  described  by 
the  term  Multiple  Cartilaginous  Exostoses 
(Fig.  525) ,  has  been  studied  by  Ehrenf ried 
(1915)  who  names  it  Hereditary  Deforming 
Chondrodysplasia,  and  by  Ashhurst  (1916); 
and  it  is  true  that  the  exostoses  are  merely 
incidental  and  not  essential  to  the  disease. 
It  may  be  transmitted  by  affected  males 
and  by  unaffected  as  well  as  by  affected 


Fig.  523.  —  Cartilaginous 
exostosis  of  outer  tuberosity 
of  left  tibia  growing  into  pop- 
liteal space.  Began  at  age  of 
sixteen  years,  and  was  re- 
moved three  years  later.  Re- 
currence noted  first  five  weeks 
ago. 


48G 


DISEASES  OF  BONE 


females.  It  appears  usually  about  the  age  of  puberty,  though  I  have 
seen  one  case  in  an  infant;  and  it  may  exist  for  some  years  before  the 
patient's  attention  is  attracted  by  the  out-growths.  These  affect 
especially  the  long  bones  of  the  extremities,  occur  mostly  at  or  near 
epiphyseal  lines  (p.  110),  and  seldom  cause  symptoms  except  from 
pressure.  If  this  exists,  the  offending  exostoses  may  be  removed. 
Patients  sometimes  claim  that  a  certain  exostosis  has  appeared  more 
or  less  suddenly,  or  that  another  has  decreased  in  size.    Disturbances 


Fig.  524. — Skiagraph  of  exostosis  of  femur  spring- 
ing from  region  of  epiphysis  and  growing  toward 
diaphysis.  Girl,  aged  sixteen  years.  Duration  two 
years.  Began  three  months  after  injury  from  runner 
of  sled.    Orthopaedic  Hospital. 


Fig.  525. — Multiple  cartil- 
aginous exostoses,  in  a  negro 
girl,  aged  thirteen  years. 
Children's  Hospital. 


of  growth,  distortions,  subluxations,  etc.,  are  frequent  in  the  long 
bones  (Bessel-Hagen,  1891).  Fibrous  exostoses  arise  either  from  peri- 
osteum o  its  attached  fascia  or  tendons.  Several  clinical  types  are 
well  known,  including  the  ivory-like  exostosis  of  the  skull  (mentioned 
at  p.  112);  subungual  exostosis,  found  almost  solely  on  the  great  toe; 
exostoses  of  the  facial  bones,  especially  the  nasal  process  of  the  maxilla 
(leontiasis  osseamay  commence  thus)  and  the  mandible;  and  exostoses 
in  connection  with  tendinous  insertions  (see  myositis  ossificans  trau- 


TUMORS  OF  BONE  487 

matica,  p.  306),  where  a  bursa  may  develop  (exostosis  bursata)  in 
which  cartilaginous  bodies  may  float. 

Fibroma*,  arising  from  periosteum,  are  rare;  they  form  one  variety 
of  polypi  in  the  nasopharynx,  and  on  the  jaw  constitute  the  "fibrous 
epulis." 

Chondromas  and  Osteomas  have  been  sufficiently  described  in 
Chapter  IV. 

Bone  Cysts. — Th.se  are  discussed  at  p.  463  in  connection  with 
fibr  cystic  osteitis.  It  is  to  be  noted  that  they  are  no  longer  regarded 
as  neoplasms.  Cystic  changes  may  occur  in  low  grade  infections,  and 
very  early  stages  of  cyst  formation  may  be  seen  in  skiagraphs  made 
for  the  diagnosis  of  some  quite  different  condition. 

Walker  and  Cummins  (1917)  refer  to  88  cases  on  record  of  echino- 
coccus  cysts  of  bone  (p.  993). 

Giant-celled  Myeloma. — This  is  described  at  p.  112. 

Bone  Aneurysms,  so-called,  may  be  of  the  type  of  false  osteoid 
aneurysm  mentioned  at  p.  113.  Usually  they  are  medullary  sarcomas 
of  highly  malignant  type  (spindle-  or  even  round-celled),  but  they 
may  arise  from  a  giant-celled  myeloma.  They  are  distinguished  from 
benign  bone  cysts  by  the  frankly  hemorrhagic  nature  of  their  con- 
tents, which  are  under  pressure;  by  much  more  rapid  growth,  early 
perforation  of  the  cortex  and  invasion  of  the  soft  tissues;  and  when 
this  stage  has  been  reached,  by  expansile  pulsation,  sometimes  accom- 
panied by  bruit.  Giant-celled  myeloma  rarely  presents  any  cystic 
center,  and  if  one  exists,  it  is  relatively  small,  and  surrounded  by 
typical  myelomatous  tissue;  whereas  in  the  pulsating  sarcomas  of 
bone,  the  blood-cyst  comprises  the  main  tumor,  and  the  sarcoma  cells 
exist  in  a  thinned-out  layer  around  the  periphery. 

Treatment. — The  treatment  of  the  malignant  type  is  prompt  dis- 
articulation above  the  affected  bone.  Local  recurrence  or  internal 
metastasis  usually  occurs  in  a  few  months,  and  death  follows  within  a 
year. 

Sarcoma. — Bone  is  one  of  the  most  frequent  sites  of  sarcoma,  and 
sarcoma  is  the  most  frequent  tumor  of  bone.  It  is  oftenest  found 
in  the  femur,  tibia,  and  pelvis.  The  tumor  may  grow  from  any  con- 
nective tissue  cells  in  the  bone,  but  not  from  myeloplaxes  nor  blood- 
forming  cells  (p.  113).  Bone  sarcomas  are  classified  clinically  as 
periosteal  and  medullary,  and  either  form  may  be  composed  of  round 
cells  or  spindle  cells;  round-celled  sarcomas  of  bone  most  frequently 
are  derived  from  medullary  tissues,  where  round  cells  (lymphocytes, 
etc.)  are  found  normally;  while  periosteal  growths  are  most  fre- 
quently spindle-celled  in  type  (see  p.  116). 

Not  every  sarcoma  growing  in  bone  tends  to  form  osseous  tissue; 
many  of  them  remain  unossified  throughout,  and  some  do  not  have 
even  calcareous  deposits:  (1)  If  the  sarcoma  arises  from  connective 
tissue  cells  in  bone  (not  osteoblastic  in  type)  it  is  properly  called 
an  osteosarcoma  (a  sarcoma  growing  in  bone) ;  (2)  such  as  are  derived 
from    bone-forming  cells  (osteoblasts)  alone  deserve  the  name  ossi- 


4SS 


DISEASES  OF  BONE 


fying  or  osteoid  sarcoma  (malignant  osteoma);  whereas  if  a  preexisting 
benign  tumor  of  bone  (osteoma,  chondroma,  myeloma?)  becomes 
sarcomatous  by  anaplasia,  it  is  termed  (3)  an  osteoma  (chondroma,  etc.) 
sarcomatodes.  In  the  first  and  last  varieties  no  true  bone  is  formed 
by  the  tumor  cells,  such  bone  as  is  present  being  either  the  original 
bone  invaded  by  the  tumor  cells,  or,  according  to  Borst  (1902),  may 
be  newly  formed  bone  due  to  stimulation  of  osteogenetic  cells  by  the 


Fig.  526. — Spindle-celled  osteosarcoma  of  femur,  eroding  bone;  in  a  girl  aged  eleven 
years.  Skiagraph  made  two  months  after  onset,  following  an  injury.  Death  from 
metastases  within  eighteen  months  of  first  symptoms.     Episcopal  Hospital. 

adjacent  tumor  cells  (such  a  stimulation  is  denied  by  Adami).  The 
histological  differentiation  of  these  types  is  difficult,  and  a  clinical 
distinction  often  is  impossible;  but,  as  the  prognosis  depends  more 
upon  the  type  of  cell  from  which  the  tumor  is  derived  than  on  the 
form  of  the  cell,  it  is  important  to  be  informed  that  a  pathological 
distinction  exists  between  these  forms  of  bone  sarcoma.  The 
most  malignant  growths  are  composed  of  the  most  highly  undiffer- 


TUMORS  OF  BONE 


489 


entiated  cells.    Thus  the  more  bone  in  a  sarcoma,  the  less  malignant 
it  is.1 

Symptoms. — The  symptoms  of  sarcoma  in  general  are  given  at 
p.  118.  Medullary  or  central  sarcoma  usually  grows  in  the  meta- 
physes  of  the  long  bones,  and 
for  a  time  is  prevented  by  the 
epiphyseal  cartilage  from  in- 
vading the  joint.  The  patient 
generally  applies  for  pain  be- 
fore much  deformity  is  present. 
Slight  uniform  expansion  of 
the  bone  end  may  be  found, 
but  the  joint  is  not  implicated; 
in  early  stages  joint  motions 
are  painless,  and  the  tumor 
pains  most  at  night,  not  during 
exercise.  These  points  serve  to 
distinguish  it  from  arthritis, 
and  may  be  the  first  symptom. 


Fig.  527. — -Periosteal  ossifying  sarcoma  of 
index  metacarpal.  Age  forty-eight  years; 
duration  six  weeks.  Amputation  of  fore- 
arm. Death  thirty  months  later,  after  three 
months'  illness  from  pulmonary  metastases. 
Episcopal  Hospital. 


Pathological    fracture    is    common, 
It  is  a  question  whether  fracture 


Fig.  528. — Periosteal  chondroma  sarcomatodes.  Age  fifty  years.  Tumor  for  twenty- 
five  years,  sudden  growth  for  three  months,  following  injury.  (See  Fig.  525.)  Refused 
any  operation.    Episcopal  Hospital. 

1  The  studies  of  M.  J.  Stewart  (1914)  on  giant  cells  were  mentioned  at  p.  116 
(footnote).  In  addition  to  the  regular  giant-cell  sarcoma  or  myeloma  (which  is 
benign),  he  recognizes  a  malignant  giant-cell  sarcoma,  which  is  equivalent  to 
a  mixed-cell  sarcoma  with  giant  cells;  the  number  of  giant  cells  varies  greatly,  and 
they  seem  to  be  developed  from  the  cells  of  stroma,  which  are  very  irregular  in 
size;  transition  forms  from  smallest  to  largest  existing.  Mitoses  are  very  frequent 
both  in  giant  cells  and  in  cells  of  matrix.  Nuclei  of  giant  cells  are  extremely 
irregular  in  size  and  shape,  but  most  are  large;  seldom  more  than  six  are  found  in 
one  cell.     Vacuolation  of  cytoplasm  is  rare. 


490 


DISEASES  OF  BONE 


ever  precedes  and  predisposes  to  sarcoma  formation.  A  skiagraph 
shows  total  destruction  of  the  bone  end,  but  a  normal  joint;  yet 
even  the  epiphysis  disappears  as  the  disease  advances.  Periosteal 
sarcoma,  usually  osteoid  in  character,  generally  affects  the  diaphyses 
of  long  bones,  early  causing  a  visible  swelling,  fusiform  in  outline, 
but  situated  mostly  on  one  side  of  the  bone,  not  encircling  it.    It 


Fig.  529. — Skiagraph  of  periosteal  chondroma  sarcomatodes.  Same  case  as  Fig.  528. 
Tumor  for  twenty-five  years,  hard,  adherent  to  bone.  Three  months  ago  the  tumor 
was  broken  from  humerus  by  a  fall.  Since  then  there  has  been  rapid  growth,  and  much 
pain.    The  tumor  has  grown  fast  again  to  the  humerus.    Episcopal  Hospital. 

is  firm  but  not  bony  to  the  touch,  thus  being  easily  distinguished 
from  the  medullary  tumors  which  are  bony  hard  until  they  thin  the 
cortex  (stage  of  spina  ventosa)  or  break  through  it.  In  a  skiagraph 
the  cortex  is  seen  to  be  more  or  less  eroded  in  the  center  of  the 
tumor  area,  and  in  advanced  cases  the  medulla  is  invaded.  Radiating 
spicules  of  newly  formed  osteoid  tissue  placed  at  right  angles  to  the 


TUMORS  OF  BONE  491 

shaft  may  be  present  between  the  cortex  and  raised  periosteum,  in 
the  center  of  the  tumor. 

Diagnosis  — A  rather  rapidly  growing  (weeks  and  months)  tumor 
in  bone,  in  a  young  adult,  sometimes  following  trauma,  and  attended 
by  increasing  pain,  deformity,  and  disability,  usually  is  a  sarcoma. 
Local  heat,  enlarged  veins,  tense  shiny  skin,  etc.,  are  present  in 
advanced  cases.  In  case  of  doubt  it  is  well  to  measure  the  limb's 
circumference  accurately  at  intervals  of  a  few  weeks;  steady  and 
progressive  increase  in  circumference  denotes  a  malignant  neoplasm. 
Any  benign  tumor  of  bone,  even  if  in  existence  for  many  years,  which, 
from  trauma  or  no  known  cause,  begins  suddenly  to  grow  rapidly, 
should  be  considered  malignant  (Figs.  528  and  529). 

Treatment. — The  usual  advice  is  to  do  amputation  as  early  as 
possible,  the  limb  being  removed  at  the  nearest  joint  above  the  dis- 
ease. But  to  one  who  considers  the  ultimate  results,  it  is  question- 
able whether  anything  is  gained  by  this  but  relief  of  pain.  Internal 
metastases  must  often  be  present  when  the  patient  first  comes  to 
the  surgeon,  since  they  appear  with  such  uniformity  even  after 
removal  of  the  limb;  and  local  recurrence  is  so  apt  to  follow  excisions 
or  amputation  in  continuity,  that  there  is  no  class  of  cases  so  dis- 
heartening. Most  patients  die  within  two  or  three  years  from  the  first 
appearance  of  symptoms  of  the  disease.  The  object  of  any  opera- 
tion is  to  remove  all  of  the  tumor,  and  this  usually  but  not  always 
implies  disarticulation.  This  is  always  preferable  to  a  long  and 
bloody  excision  or  to  any  operation  which  will  leave  a  useless  limb. 
If  the  patient  regains  some  measure  of  health  and  comfort  even  for 
a  few  months,  before  visceral  metastases  make  their  presence  known, 
the  operation  cannot  be  said  to  have  been  done  in  vain.  Coley's 
fluid  (p.  118)  should  be  employed  as  a  routine,  since  at  least  it  can  do 
no  harm,  and  may  be  of  value1.  Opiates  should  be  administered  freely 
in  the  latter  stages. 

Carcinoma. — Carcinoma  of  bone  occurs  as  a  metastatic  growth, 
being  especially  frequent  in  cases  of  prostatic  and  thyroid  carcinoma, 
but  is  also  seen  in  carcinoma  of  the  mammary  gland,  uterus,  etc. 
In  the  long  bones  the  first  symptom  frequently  is  pathological  frac- 
ture, and  this  occurrence  always  should  lead  to  search  for  primary 
carcinoma,  past  or  present.  The  fractures  usually  unite  without  diffi- 
culty. In  the  spine,  secondary  carcinoma  usually  is  a  direct  extension 
from  mammary  or  visceral  carcinoma.  Local  treatment  is  useless. 
The  intolerable  pain  of  vertebral  invasion  should  be  relieved  by 
opium  given  until  effective;  or  the  dorsal  roots  of  the  nerves  may 
be  divided  intraspinally. 

1  Coley  (1919)  reports  38  out  of  249  patients  with  bone  sarcoma,  treated  by  the 
mixed  toxins,  as  being  alive  and  well  over  three  years  after  institution  of  treat- 
ment. Five  patients  had  recurrence  after  a  three  year  interval  of  good  health. 
He  now  believes  amputation  never  is  indicated  for  sarcoma. 


CHAPTER   XV. 

DISEASES  OF  JOINTS. 

DYSTROPHIES  OF  JOINTS. 

It  was  pointed  out  in  the  last  chapter,  in  the  section  dealing  with 
Dystrophics  of  Hour,  that  some  of  these  conditions  at  times  were 
associated  with  changes  in  the  organs  of  internal  secretion.  Thus, 
Acromegaly  is  very  constantly  associated  with  changes  in  the  hypophy- 
sis cerebri;  Achondroplasia  has  been  found  associated  with  patho- 
logical alterations  in  the  thyroid;  Osteogenesis  Imperfecta,  with 
changes  in  the  adrenals;  Osteomalacia,  with  changes  in  the  ovaries, 
while  the  administration  of  thymus  or  thyroid  extract  sometimes  is 
of  benefit  in  cases  of  Osteitis  Deformans. 

As  in  the  case  of  bone  diseases,  so  in  those  which  affect  the  joints, 
there  is  a  class  of  chronic  affections  not  definitely  inflammatory, 
though  possibly  due  to  remote  or  attenuated  infection,  to  toxemias 
or  intoxications,  or  to  changes  in  the  organs  of  internal  secretion. 
Until  more  definite  knowledge  concerning  them  is  gained,  it  is  con- 
venient to  class  them  as  dystrophies,  since  at  least  it  is  certain  that 
their  more  immediate  cause  is  to  be  sought  in  disturbances  of  nutrition. 
If  it  be  asked  why  disorders  due  to  disturbances  of  nutrition  affect 
the  bones  and  joints  rather  than  the  soft  parts,  it  may  be  replied 
that  the  bones  and  joints  have  a  less  free  and  active  circulation  than 
the  soft  parts,  and  like  the  hair,  nails,  teeth,  etc.,  give  early  evidence 
of  circulatory  disturbance;  moreover,  the  soft  parts  themselves  are 
affected,  but  less  conspicuously  than  the  bones  and  joints.  Slight 
constantly  recurring  injuries,  moreover,  showT  their  effects  more  on 
the  joints  than  the  soft  parts,  and  sometimes  have  a  very  marked 
influence  in  localizing  trophic  lesions  in  one  joint  or  set  of  joints 
rather  than  in  others. 

The  pathological  changes  in  these  dystrophic  joints  are  those 
of  atrophy  and  hypertrophy;  they  may  exist  separately  or  together, 
but  in  almost  every  case  one  change  or  the  other  predominates  so 
that  the  disease  can  be  classed  either  as  atrophic  or  hypertrophic 
in  type.  It  is  possible  that  the  atrophic  type  is  a  more  acute  mani- 
festation of  the  same  disease  which  in  subacute  or  chronic  form  corre- 
sponds to  what  is  described  as  the  hypertrophic  type.  The  lesions 
may  affect  the  synovial  membrane  only,  or,  as  is  much  more  fre- 
quently the  case,  the  bones  and  cartilages  as  well;  and  in  most  cases 
it  is  these  structures  wThich  are  first  involved,  the  synovial  membrane 
being  implicated  secondarily.  One  joint  or  many  may  be  affected, 
the  disease  being  classed  as  monarticular  or  polyarticular. 
(492) 


ATROPHIC  JOINT  LESIONS  493 

The  nomenclature  of  these  diseases  is  much  confused:  two  terms, 
Rheumatoid  Arthritis  and  Arthritis  Deformans  have  been  employed 
indiscriminately  by  many  writers,  and  have  been  applied  to  various 
different  diseases;  so  that  if  a  surgeon  today  refers  to  a  disease  by 
either  of  these  terms,  no  one  knows  to  what  disease  he  refers  unless 
he  further  defines  his  meaning.  Speaking  generally,  however,  the 
term  rheumatoid  arthritis  usually  has  been  applied  to  chronic  joint 
diseases  in  which  synovial  lesions  were  believed  to  predominate;  and 
osteo-arthritis,  or  arthritis  deformans,  to  those  forms  in  which  bony 
changes  are  preeminent.  The  relation  of  these  joint  dystrophies 
to  affections  of  the  organs  of  internal  secretion  is  by  no  means  so 
evident  as  in  some  of  the  bone  dystrophies,  to  which  reference  was 
made  above.  But  the  favorable  influence  exerted  by  a  long  course  of 
treatment  of  thymus  gland  extract  upon  atrophic  joint  lesions  is  well 
recognized,  and  the  development  of  hypertrophic  joint  lesions,  in 
women,  at  a  time  when  ovarian  and  thyroid  changes  are  frequent,  is 
a  fact  to  which  Llewellyn  Jones  has  called  attention. 

It  is  customary  to  speak  of  all  these  joint  affections  as  different 
forms  of  arthritis,  though  this  term  implies  an  inflammatory  rather 
than  a  degenerative  condition.  Yet  these  dystrophic  joint  diseases 
have  certain  features  which  distinguish  them  from  infections  of  joints, 
and  which  it  is  very  important  to  bear  in  mind.  Our  present  knowl- 
edge of  the  subject  is  due  largely  to  the  investigations  of  Goldthwait, 
Nathan,  and  Llewellyn  Jones  (1909).  The  dystrophies  begin  insidi- 
ously, are  not  attended  by  marked  phenomena  of  inflammation  nor 
by  constitutional  reaction;  they  gradually  progress,  invading  other 
joints  one  by  one;  may  exhibit  slight  remissions  and  exacerbations; 
but  the  joints  once  affected  never  entirely  recover,  and  there  is  no 
definite  end  to  the  disease.  The  infections  have  a  definite  and  easily 
remembered  commencement;  are  attended  by  the  usual  inflammatory 
phenomena  and  constitutional  reaction,  even  if  slight  in  degree; 
usually  all  the  joints  affected  are  attacked  at  or  about  the  same  time; 
and  when  once  the  infection  has  run  its  course,  the  disease  is  gone, 
and  the  joints  recover,  or  retain  permanent  but  never  progressive 
disability. 

Atrophic  Joint  Lesions. — Here  is  placed  a  disease  named  "atrophic 
arthritis"  by  Goldthwait  (1905),  and  "metabolic  osteoarthritis" 
by  Nathan  (1906);  it  is  the  same  as  the  "rheumatisme  noueux"  of 
Trousseau  (1868),  the  "chronic  progressive  articular  rheumatism" 
of  Charcot  (1874),  the  "arthritis  nodosa"  of  Waldmann  (1884),  the 
"arthritis  deformans"  of  Baumler  (1897),  and  the  "primary  progres- 
sive chronic  joint  rheumatism"  of  Pribram  (1902).  It  is  a  poly- 
articular, symmetrical  affection,  occurring  in  women  oftener  than 
in  men,  and  generally  beginning  in  the  fingers  and  hands,  where  it 
may  be  localized  by  repeated  slight  trauma.  It  is  seen  oftenest  in 
young  adults,  but  sometimes  occurs  in  children.  It  affects  first 
the  smaller  joints  of  the  hands  and  feet,  especially  the  proximal 
interphalangeal   joints  of  the   fingers;   it    progresses   through  many 


404 


DISEASES  OF  JOINTS 


years,  invading  the   wrists,  elbows,  shoulders,  ankles,  knees,  spine, 
and  maxillary  joints.    The  hips  seldom  are  affected. 

The  pathological  change  first  noted  is  a  localized  subchondral  atrophy 
of  the  joint  ends,  giving  them  a  "punched  out"  appearance  in  a 
skiagram  (Fig.  530);  these  are  minute  bone  cysts,  due  to  osteoporosis 
and  lacunar  resorption  (Nathan,1  1909).  Later  the  overlying  cartilage 
degenerates,  becomes  invaded  by  connective  tissue  from  the  under- 
lying spongiosa,  and  a  so-called  cartilaginous  decubitus  (pressure 
sore)  is  produced  by  pressure  of  the  opposing  bone.     The  cartilage 


Fig.  530. — Skiagraph  of  atrophic  arthritis  of  hands.  Girl,  aged  twenty-one  years; 
duration  two  years.  Note  bone  cyst  in  distal  end  of  proximal  phalanx  of  middle  finger 
of  left  hand;  absorption  of  heads  of  metacarpal  bones  in  both  hands;  and  atrophic 
changes  in  bones  of  right  carpus.    Orthopaedic  Hospital. 


becomes  completely  absorbed,  the  joint  cavity  is  lost,  being  filled 
by  loose  and  vascular  connective  tissue  which  shows  no  tendency  to 
contraction,  and  ankylosis  (p.  508)  rarely  or  never  occurs.  In  skia- 
graphs of  advanced  cases  the  joints  appear  to  be  ankylosed,  because 
the  bones  are  in  immediate  contact  or  overlap,  no  clear  cartilaginous 
area  intervening  (Fig.  531).  The  joints  become  distorted,  and  sub- 
luxated  from  muscular  contraction;  and  in  weight-bearing  joints,  as 

1  Poncet  considers  such   changes   characteristic  of  one  form  of   "tuberculous 
rheumatism"  (see  p.  517). 


ATROPHIC  JOINT  LESIONS 


495 


the  knee,  the  bone  ends  may  become  broadened  and  mashed  out 
rather  flat,  owing  to  their  atrophic  state.  No  reactionary  phenomena 
are  visible;  no  attempts  at  repair  are  made;  no  ecchondroses  or  osteo- 
phytes are  formed. 


Fig.  531.- — Skiagraph  of  atrophic  arthritis  of  hands.  Woman,  aged  thirty  years: 
duration  five  years.  Changes  more  advanced  than  in  Fig.  530.  Subluxations  and 
apparent  ankyloses.   (See  Fig.  532.)  Orthopaedic  Hospital. 

Symptoms  — The  pathological  changes  shown  in  Fig.  530  may 
have  existed  for  many  months  before  subjective  symptoms  arrest  the 
patient's  attention.      Usually  the  first  complaint  is  of   stiffness  in 


Fig.  532. — Atrophic  arthritis.     Duration  six  years.     Same  patient  as  in  Fig.  531. 


the  fingers,  worse  in  the  morning  and  gradually  passing  away  after 
use;  and  the  patient  is  dosed  for  "rheumatism."  But  on  examina- 
tion this  is  found  not  to  be  real  stiffness,  but  rather  weakness,  passive 


196 


DISEASES  OF  JOINTS 


motion  being  tree  and  often  painless.  Muscular  atrophy  is  pro- 
nounced, and  often  increases  the  swollen  appearance  of  the  joints 
(Fig.  532).  Synovia]  effusion  is  rare,  except  from  over-exertion  or 
trauma;  it  may  be  attended  by  considerable  pain,  but  both  pain  and 
effusion  subside  when  the  joints  are  put  at  rest.  Joint  deformity 
follows  destruction  of  bone  ends  and  muscular  contraction;  but, 
though  motion  may  be  limited  or  even  abolished  by  periarticular 
changes,  it  is  free  within  the  range  allowed.     Motion  is  most  limited 


Fig.  533. — Skiagraph  of  atrophic  arthritis  of  hands,  advanced  stage.  Woman,  aged 
sixty-five  years;  duration  forty -five  years.  Marked  bone  absorption,  many  subluxa- 
tions. Two  years  later  skiagraphs  showed  scarcely  any  bone  left  in  shafts  of  meta- 
carpals.    (See  Fig.  534.)  Episcopal  Hospital. 

in  the  larger  joints;  in  advanced  cases  the  smaller  joints  may  become 
flail-like,  and  the  skin  covers  the  phalanges  like  a  wrinkled  glove 
(Figs.  533  and  534).  Lateral  deviation,  flexion,  or  hyperextension  of 
the  phalanges  may  occur,  and  several  different  deformities  may  exist 
in  the  same  hand.  The  only  constitutional  symptoms  are  those  of 
slight  cachexia  and  secondary  anemia. 

Prognosis. — The  prognosis  is  gloomy.  The  disease  steadily  pro- 
gresses, and  in  most  cases  the  patient  eventually  becomes  a  helpless 
cripple. 


HYPERTROPHIC  JOINT  LESIONS  497 

Treatment. — Good  feeding  and  hygiene  are  required;  I  have  seen 
improvement  in  some  patients  under  the  care  of  Pemberton,  whose 
plan  of  treatment  is  based  on  metabolic  studies,  and  is  largely  dietetic 
in  nature  (1913).  Medicines  are  of  little  value,  but  Nathan  reports 
increasingly  favorable  results  from  thymus  extract,  in  doses  of  10  to 
20  grains  three  times  daily.  Guaiacol  carbonate  sometimes  is  useful, 
in  doses  of  from  5  to  15  grains  three  times  daily,  continued  for  at 
least  a  year.  This  should  be  combined  with  potassium  iodide  and 
tonics.  Rest  is  necessary  when  exacerbations  occur  from  trauma 
or  over-use;  it  often  is  best  enforced  by  use  of  orthopedic  apparatus. 
Massage,  hot  baths,  baking,  etc.,  and  exercise  short  of  fatigue,  are  of 
some  value.  After  subsidence  of  acute  symptoms,  deformity  should 
be  corrected  by  weight-extension  and  tenotomy,  or  even  by  forcible 
manipulation,  though  this  is  more  apt  to  fracture  the  bones  than 
overcome  periarticular  contractures.  In  one  advanced  case  I  excised 
both  knees  for  deformity,  and  the  patient  is  now  able  to  be  about  and 
attend  to  her  housekeeping. 


Fig.  534. — Atrophic  arthritis  (advanced  stage).     Same  patient  as  Fig.  533. 
Episcopal  Hospital. 

Hypertrophic  Joint  Lesions. — These,  as  pointed  out  at  p.  594, 
are  not  rare  as  results  of  attenuated  or  remote  infections;1  but  there 
are  also  certain  forms  of  hypertrophic  joint  disease  which  seem  to 
be  pure  disorders  of  nutrition.  In  the  polyarticular  form,  "Heber- 
den's  nodes"  (1804)  are  found;  these  consist  essentially  in  hyper- 
trophies of  the  bases  of  the  distal  digital  phalanges,  often  accom- 
panied by  lateral  deviation  of  the  terminal  phalanx  (Fig.  535).  The 
thumb  rarely  is  affected.  The  monarticular  form  is  of  more  interest 
to  surgeons.  It  is  the  "arthritis  deformans"  of  Volkmann  (1882), 
Schiiller  (1900),  and  Hoffa  (1906),  the  "chronic  partial  rheumatism" 
of  Charcot  (1874),  and  the  "hypertrophic  arthritis"  of  Goldthwait 
(1905).  In  this  disease  the  influence  of  trauma  frequently  is  con- 
spicuous, hypertrophic  lesions  developing  in  a  joint  injured  perhaps 
many  years  before  (Fig.  453),  or  in  one  which  constantly  is  subject  to 
slight  injury  or  strain.    Static  strain,  from  imperfectly  reduced  fracture, 

1  They  form  another  variety  of  the  "tuberculous  rheumatism"  of  Poncet  (p.  517). 
32 


498 


DISEASES  OF  JOINTS 


or  faulty  attitudes,  often  is  a  cause.  The  disease  affects  men  more 
than  women,  usually  those  past  forty  years;  and  arteriosclerosis  seems 
to  be  a  predisposing  factor.  Sometimes  the  affection  is  called  senile 
arthritis,  and. when  the  hip  is  attacked,  it  is  known  as  "morbus  coxse 
senilis."  As  a  matter  of  fact,  however,  the  knee  is  more  often  affected 
than  the  hip,  especially  in  women;  in  men  the  hip  and  spine  are 
oftener  attacked.  In  the  spine  the  disease  is  called  "spondylitis 
deformans"  (p.  663). 


Fig.  535. — Skiagraph  of  hands  of  patient,  aged  sixty-three  years,  with  polyarticular 
hypertrophic  arthritis.  Insidious  onset,  many  years  ago.  Note  hypertrophies  of  bases 
of  distal  phalanges  ("Heberden's  nodes")  and  periosteal  proliferations  along  shafts  of 
proximal  and  middle  phalanges.    Orthopa?dic  Hospital. 


The  earliest  pathological  change  is  said  to  occur  in  the  joint  car- 
tilage; this  shows  attempts  at  proliferation,  but  the  cartilage  cells 
which  border  on  the  joint  cavity  are  discharged  into  the  synovial 
fluid,  and  the  underlying  cartilage  is  worn  down  by  attrition  of  the 
opposing  bone,  producing  a  "cupping"  of  the  joint  surface;  while 
the  more  fortunate  cartilage  cells  not  subjected  to  such  pressure 
proliferate  into  the  attachments  of  the  capsule,  and  so  produce  spurs, 
ecchondroses,  and  osteophytes,  which  cause  a  "lipping"  at  the  joint 
margins.  The  bone  ends  themselves  often  are  the  seat  of  porosis, 
and  in  weight-bearing  joints,  especially  the  hip,  very  marked  altera- 


HYPERTROPHIC  JOINT  LESIONS 


499 


tions  in  the  shape  of  the  bone  ends  may  occur;  thus  the  head  of  the 
femur  may  be  worn  away,  the  acetabulum  enlarged  upward  and 
backward  ("wandering  acetabulum"),  while  the  base  of  the  femoral 
neck  and  the  acetabular  borders  become  studded  with  osteophytes. 
The  angle  between  the  neck  and  shaft  of  the  femur  is  decreased,  and 
coxa  vara  results.  The  earliest  skiagraphic  evidences  of  these  bone 
changes  are  observed  in  sharper  angularity  of  the  bone  margins. 
The  edges  of  the  tibial  condyles  become  sharp,  the  patella  becomes 
square,  the  astragalus  and  scaphoid  lose  their  gentle  curves,  and 


Fig.  536. — Skiagraph  of  monarticular  hypertrophic  arthritis  of  knee.  Woman,  aged 
forty-nine  years.  Duration  two  years.  Insidious  onset;  no  injury.  (See  Fig.  537.) 
Orthopaedic  Hospital. 

eventually  distinct  exostoses  are  observed  (Figs.  536  and  537).  These 
occur  especially  at  points  of  strain,  where  ligaments  or  tendons  are 
attached ;  they  are  not  always  confined  to  the  immediate  neighborhood 
of  joints.  The  joint  ligaments  may  be  gradually  destroyed  by  the 
degenerative  process,  and,  according  to  Marsh  (1910),  the  joint  may 
become  weakened,  loose,  even  flail-like;  this  occurs  oftenest  in  the  knee. 
Usually,  however,  for  a  time  at  least,  limitation  of  motion  is  observed 
owing  to  periarticular  fibrous  changes  or  the  interlocking  of  osteo- 
phytes, but  ankylosis  rarely   or   never   occurs.     If  the  obstructing 


500 


DISEASES  OF  JOINTS 


osteophytes  are  removed,  free  motion  may  be  restored  for  a  time. 
In  the  shoulder-joint  the  long  tendon  of  the  biceps  may  fuse  with 
the  underlying  bone. 

Symptoms. — The  patient  complains  of  weakness  and  stiffness  in 
the  affected  joint.  It  creaks  on  motion,  and  motion  commonly  is 
limited.  Severe  referred  pain  as  well  as  local  pain  may  be  felt.  The 
general  health  is  not  materially  impaired.  If  the  small  joints  are 
affected  they  present  Heberden's  nodes,  but  rarely  give  subjective 


Fig.  537. — Hypertrophic  arthritis  of  knee,  lateral  view.     Same  patient  as  Fig.  536. 

Orthopaedic  Hospital. 


symptoms.  The  disease  typically  is  monarticular  in  the  beginning, 
and  often  remains  so;  but  other  joints  may  be  involved  in  time.  The 
diagnosis  depends  on  excluding  an  infectious  origin,  which  often  is 
difficult,  and  sometimes  impossible;  on  observing  the  localization 
of  the  process  to  one  of  the  larger  joints  which  has  been  injured  or 
is  the  seat  of  constant  strain  or  repeated  slight  trauma;  and  on  the 
results  of  skiagraphic  examination.  Atrophic  arthritis  is  polyar- 
ticular, affects  first  the  smaller  peripheral  joints,  and  spreads  cen- 
tripetally,  and  occurs  in  women  in  early  adult  life.     Hypertrophic 


HYPERTROPHIC  JOINT  LESIONS 


501 


arthritis  is  monarticular,  affects  a  large  joint,  and  occurs  in  persons 
past  middle  life.  Both  have  an  insidious  onset,  are  chronic  from  the 
start,  run  a  long  and  tedious  course,  and  neither  is  accompanied  by 
inflammatory  or  constitutional  symptoms. 

Treatment. — Sometimes  it  may  be  possible  to  prevent  the  devel- 
opment of  hypertrophic  lesions  by  relieving  a  joint  from  strain, 
protecting  it  from  injury,  or  by  active  treatment  of  an  underlying  con- 
dition, such  as  internal  derangement  of  the  knee-joint  (p.  448).  In  the 
cure  of  the  disease,  a  painful  joint  should  be  put  at  rest.  Confinement 
to  bed  seldom  is  necessary,  the  use  of  plaster  of  Paris,  splints,  braces, 
etc.,  usually  being  sufficient.  Immobilization  should  not  be  absolute, 
however,  nor  should  it  be  continued  too  long,  since  this  promotes 
stiffness.     Such  exercises  as  can  be  taken  without  too  great  fatigue 

should  be  encouraged.  Occasionally 
one  or  more  bony  spurs  which 
markedly  limit  motion,  or  cause 
pressure  symptoms,  may  be  re- 
moved by  saw  or  chisel.  Arthro- 
desis (p.  570)  has  been  employed 
in  some  cases,  especially  at  the 
hip  (Figs.  538  and  539)  and  the 
knee,  to  relieve  pain  by  permanent 


Fig.  538. — Albee's   method  of   arthro- 
desis of  the  hip     (See  Fig.  539.) 


Fig.  539. — Albee's  method  of  arthro- 
desis of  the  hip. 


Fig.  540. — Charcot  joint.  Age  fifty-one 
years.  Duration,  three  months;  followed 
sprain  while  climbing.  Lost  knee-jerks  and 
Argyll-Robertson  pupils.  Orthopaedic  Hos- 
pital. 


joint-fixation.    General  hygienic  treatment  is  of  value,  but  no  drug 
has  much  influence  on  the  disease. 


502  DISEASES  OF  JOINTS 

Neuropathic  Joints  (Charcot,  1868). — In  tabes  dorsalis  the  joints 
are  subjected  t<>  unusual  strain,  as  deep  sensation  is  lost,  and  the 
patient  is  not  aware  of  the  injury  he  inflicts  upon  them  in  walking, 
pulling  lvmself  up  stairs,  etc.;  the  nutrition  of  the  bones  also  is  dis- 
turbed, predisposing  them  to  distortion  and  fracture.  So-called 
spontaneous  fracture  is  not  rare,  and  sometimes  occurs  some  time 
before  definite  tabetic  symptoms  develop.  As  a  rule  only  one  joint  is 
affected  by  the  dystrophy,  most  often  the  knee;  but  the  shoulder, 
elbow,  ankle,  hip,  and  even  spine  sometimes  are  affected.  Painless 
effusion  may  be  the  first  symptom,  and  this  may  exist  so  long  as  to 
induce  relaxation  of  the  ligaments,  or  even  a  flail-joint,  before  the 
patient  realizes  its  condition  (Fig.  540).  The  bone  ends  become  dis- 
torted from  pressure,  and  pieces  may  be  broken  off  and  lie  free  in  the 
joint.  Osteophytes  frequently  grow  in  the  fibrous  tissues  surrounding 
the  joint. 

Diagnosis. — The  diagnosis  depends  on  the  detection  of  constitu- 
tional symptoms  of  tabes,  associated  with  a  nearly  painless  dystrophy 
of  one  of  the  larger  joints,  with  effusion  and  abnormal  mobility. 
In  syringomyelia  similar  changes  may  occur,  usually  in  the  upper 
extremity. 

Treatment. — This  consists  in  care  of  the  general  tabetic  condition, 
and  support  to  the  diseased  joint;  massage  may  improve  the  con- 
dition of  the  surrounding  muscles.  In  some  cases  arthrodesis  may  be 
done,  in  the  endeavor  to  restore  stability.  Very  rarely  amputation 
may  be  required. 

LOOSE  BODIES  IN  JOINTS. 

This  condition  has  many  of  the  same  symptoms  as  internal  derange- 
ment of  the  knee-joint,  referred  to  at  p.  448,  but  the  pathogenesis 
is  different.  The  knee  is  affected  in  the  vast  majority  of  cases.  The 
loose  bodies,  or  "joint  mice"  as  they  are  called,  may  be  entirely  free, 
or  may  remain  attached  to  the  capsule  by  a  pedicle.  They  may  be 
derived  from  hypertrophied  synovial  fringes,  from  organized  blood- 
clot,  flakes  of  fibrin,  etc.;  from  detached  chips  of  bone  or  cartilage; 
or  from  ecchondroses,  osteophytes,  etc.,  developed  in  hypertrophic 
arthritis.  One  or  an  innumerable  number  of  such  bodies  may  be 
present. 

Symptoms. — The  symptoms  are  those  of  the  underlying  disease 
(villous,  or  hypertrophic  arthritis),  or  of  old  injury,  with  occasional 
locking  of  the  joint  from  impaction  of  the  loose  body.  This  often 
is  followed  by  an  attack  of  acute  synovitis.  If  the  loose  bodies  are 
large,  or  present  in  sufficient  numbers,  they  may  be  detected  by 
palpation,  and  sometimes  they  are  dense  enough  to  be  detected  in  a 
skiagraph.  Care  should  be  taken  not  to  mistake  a  normal  sesamoid 
bone  or  other  extra-articular  structure  for  a  loose  body. 

Treatment. — Usually  nothing  short  of  arthrotomy  and  removal 
of  the  bodies  will  give  relief,  unless  the  joint  is  kept  immobilized; 
and  even  after  such  an  operation  the  joint  lesion  which  caused  the 
formation  of  the  loose  bodies  will  require  its  appropriate  treatment. 


INFECTIONS  OF  JOINTS 


503 


INFECTIONS  OF  JOINTS. 

Pathology. — Infection  may  reach  a  joint  through  external  wound, 
directly  through  the  blood-stream,  or  from  a  neighboring  focus  of 
inflammation,  usually  in  bone.  Wounds  of  joints  have  been  considered 
in  Chapter  XIII.  Most  joint  infections  secondary  to  bone  lesions 
are  tuberculous  in  origin;  these  are  discussed  at  p.  519.  In  this 
place  it  is  desired  merely  to  enumerate  briefly  the  main  pathological 
changes  which  occur  in  joints  as  the  result  of  infection. 

Synovitis  is  the  earliest  stage;  the  synovial  membrane  is  congested 
and  swollen,  and  minute  ecchymotic  areas  may  be  present  in  it; 
effusion  into  the  joint  cavity  occurs,  due  both  to  increase  in  the 
natural  synovial  secretion  and  to  the  formation  of  inflammatory 
lymph.  Fluid  collects  in  the  joint  because  it  is  a  free  surface,  and 
wherever  a  free  surface  exists  effusion  predominates  over  edema. 
In  mild  infections,  and  in  aseptic  inflammations  such  as  sprains, 
contusions,  etc.,  the  effused  fluid  usually  remains  serous  in  type;  but 
infections  due  to  pyogenic  cocci  usually,  and  those  caused  by  the  pneu- 
mococcus,   gonococcus,  etc.,  often  end  in  suppuration,  constituting 


Fig.  541. — Pyarthrosis  of  wrist.     Residual  abscess  three  months  after  complete 
healing  of  infected  hand  and  forearm.     Orthopaedic  Hospital. 


the  condition  of  pyarthrosis  or  empyema  articuli  (Fig.  541).  Arthritis 
is  a  clinical  term  used,  in  contradistinction  to  synovitis,  to  imply 
predominant  involvement  of  structures  of  the  joint  other  than  the 
synovial  layer  of  the  capsule;  and  osteoarthritis  signifies  involvement 
of  the  bone  ends.  In  some  cases  of  subacute  infection  no  marked 
effusion  occurs,  but  proliferation  of  the  synovial  villi  is  the  main 
feature,  producing  villous  arthritis;  this  is  believed  by  some  to  be 
caused  by  a  specific  diplococcus,  discovered  in  1900  by  Schiiller. 

If  recovery  ensues  while  the  effusion  is  still  serous,  little  subse- 
quent trouble  may  be  experienced;  often,  however,  the  fluid  is  not 
entirely  absorbed,  and  chronic  serous  synovitis  (hydrops  articuli,  p.  505) 
develops.  When  the  exudate  has  been  sero-fibrinous  some  organiza- 
tion of  the  inflammatory  material  usually  occurs,  and  the  joint  cavity 
is  more  or  less  obliterated  by  bands  of  adhesions,  which  may  restrict 
motion.  When  suppuration  has  occurred,  more  or  less  destruction 
of  the  cartilages,  ligaments,  etc.,  is  inevitable;  complete  disorganiza- 
tion of  the  joint  may  occur;  and  as  gradual  repair  by  organization 
and  cicatrization  sets  in,  the  bones  become  welded  together,  more  or 
less  firmly,  and  frequently  in  bad  position,  in  a  condition  of  ankylosis 


51 1 1  DISEASES  OF  JOINTS 

(p.  508).  Ankylosis  may  be  entirely  bony,  or  due  to  fibrous  adhesions 
allowing  a  very  limited  range  of  motion;  limitation  of  motion  due  to 
periarticular  changes  (contraction  of  capsule,  ligaments,  tendons; 
locking  of  osteophytes,  etc.)  is  not  spoken  of  as  ankylosis,  which  term 
always  implies  loss  of  motion  from  intra-articular  adhesions,  fibrous  or 
osseous  in  character.  Owing  to  the  distention  of  the  capsule  during 
the  stage  of  effusion,  and  to  changes  in  the  bone  ends,  pathological 
dislocation  of  the  joint  may  occur,  from  muscular  action,  or  the 
force  of  gravity. 

Symptoms. — Joint  effusion  is  shown  by  increase  in  circumference, 
with  bulging  of  the  capsule  at  its  weakest  parts.  In  the  knee  the 
patella  is  floated  up  from  the  condyles,  and  when  the  quadriceps 
extensor  is  relaxed,  the  patella  can  be  made  to  tap  against  the  bone; 
the  capsule  bulges  on  each  side  of  the  quadriceps  tendon,  and  the  quad- 
riceps bursa  is  distended  (Fig.  542).  When  much  fluid  is  present 
fluctuation  can  be  elicited.  In  the  elbow  the  capsule  bulges  on  both 
sides  of  the  triceps  tendon;  in  the  ankle,  beneath  the  tendo  Achillis 
and  anteriorly.  In  the  wrist  swelling  is  more  marked  on  the  dorsum; 
while  in  the  hip  and  shoulder  effusion  is  more  difficult  to  appreciate. 
Any  joint  which  is  the  seat  of  effusion  tends  to  assume  a  position 
in  which  the  capsule  is  most  relaxed;  this  usually  is  in  moderate 
flexion,  and  in  the  hip  slight  abduction  as  well  as  flexion  is  charac- 
teristic. Great  pain  is  felt  in  the  affected  joint,  and  from  pressure 
of  the  effusion  on  neighboring  nerves  referred  pain  may  exist.  Mus- 
cular spasm  is  present,  and  may  cause  starting  or  jumping  pains 
in  the  joint,  from  time  to  time,  especially  during  sleep.  Joint  motion 
is  painful,  and  the  joint  itself  is  tender.  As  a  rule,  the  bone  ends  are 
not  tender  in  simple  synovitis  nor  in  arthritis  not  secondary  to  osseous 
disease;  but  crowding  the  bones  together  causes  pain.  The  affected 
joint  may  be  hot  even  in  simple  synovitis,  but  unless  suppuration  is 
present  there  is  not  much  constitutional  disturbance,  nor  is  the 
affected  joint  red.  Suppuration  may  be  ushered  in  by  a  chill,  or  there 
may  be  no  change  except  in  the  temperature.  In  pyarthrosis  of  the 
larger  joints  the  patient  becomes  gravely  ill,  and  all  the  constitutional 
signs  of  septicemia  or  pyemia  develop.  The  joint  becomes  more  tense 
and  painful,  exquisite  tenderness  develops,  dusky  redness  with  edema 
of  the  skin  may  be  present,  and  unless  the  pus  is  evacuated  it  may 
perforate  the  capsule  and  invade  the  soft  parts.  Spontaneous  dis- 
location is  most  frequent  in  the  hip. 

If  villous  arthritis  develops,  the  joint  does  not  present  fluctuation, 
but  is  doughy,  and  the  capsule  does  not  bulge  but  presents  a  more 
uniform  enlargement,  and  it  is  evident  that  this  is  due  partly  to  peri- 
articular thickening.  The  condition  becomes  subacute  or  chronic, 
and  is  then  characterized  by  creaking  and  crackling  on  motion,  slight 
permanent  loss  of  full  extension,  and  moderate  disability. 

Treatment. — The  treatment  of  acute  synovitis  consists  in  local 
rest  of  the  joint,  secured  by  proper  splinting,  and  in  the  case  of  the 
lower  extremity  by  rest  in  bed,  usually  with  weight  extension.     If 


CHRONIC  SEROUS  SYNOVITIS  505 

this  treatment  is  instituted  promptly,  apparent  recovery  may  ensue 
in  a  few  days;  but  the  joint,  especially  the  knee,  should  be  protected 
for  several  weeks  by  a  light  plaster  case,  as  recurrence  of  effusion, 
and  development  of  hydrops  is  much  to  be  feared.  Massage  of  the 
surrounding  muscles,  not  of  the  joint  itself,  is  of  value  for  restoration 
of  function  after  all  inflammatory  symptoms  have  been  absent  for 
several  weeks.  When  the  patient  comes  under  observation  at  a 
later  stage,  with  the  joint  in  bad  position,  or  suppuration  threatening, 
weight  extension  should  be  applied  as  well  as  splinting;  the  latter 
alone  sometimes  is  sufficient  for  the  upper  extremity.  The  joints 
should  be  kept  in  the  position  which  will  be  least  useless  should 
ankylosis  occur:  the  shoulder  in  slight  abduction;  the  elbow  and 
ankle  at  a  right  angle;  the  wrist  and  knee  in  full  extension;  and  the 
hip  in  full  extension  and  slight  abduction,  but  without  either  external 
or  internal  rotation.  The  forearm  should  be  kept  nearly  in  full 
supination. 

Suppuration  is  treated  by  aspiration  (which  may  be  used  as  a 
diagnostic  measure)  and  injection  of  a  few  cubic  centimeters  of  a 
2  per  cent,  formalin-glycerin  solution,  the  joint  meantime  being  kept 
at  rest,  and  such  constitutional  measures  being  used  as  the  patient's 
condition  demands.  Aspiration  and  formalin  injection  may  be  repeated 
a  number  of  times,  though  the  injection  may  be  very  painful;  and 
usually  the  infection  may  be  controlled  in  this  way,  the  fluid  grad- 
ually becoming  serous,  and  the  joint  inflammation  subsiding  with 
preservation  of  a  fair  degree  of  motion.  Should,  however,  improve- 
ment not  be  secured  after  two  or  three  aspirations,  and  at  once  if 
pus  has  perforated  the  capsule  and  invaded  the  soft  parts,  the  joint 
should  be  incised,  and  treated  as  detailed  for  septic  arthritis  following 
trauma  (p.  423). 

Villous  arthritis,  when  acute,  is  treated  as  synovitis,  by  rest,  and 
antiphlogistic  or  sorbefacient  applications.  In  its  more  usual  sub- 
acute or  chronic  stage,  benefit  is  derived"  from  massage,  passive 
motion,  baking,  hot  and  cold  douches,  passive  congestion,  etc.  Any 
source  of  infection  (see  p.  516)  should  be  removed,  and  the  patient's 
general  health  improved.  Painful  joints  should  be  supported  by 
suitable  apparatus.  Arthrotomy,  with  excision  of  hypertrophied 
synovia  is  most  often  required  at  the  knee. 

Acute  Arthritis  of  Infants  (T.  Smith,  1874).    See  footnote  p.  479. 

Chronic  Serous  Synovitis,  or  Hydrops  Articuli,  occurs  oftenest 
in  the  knee,  usually  the  result  originally  of  slight  trauma  causing 
acute  synovitis  with  effusion,  which  has  never  entirely  subsided, 
owing  to  inefficient  treatment,  for  which  the  patient  is  more  often 
to  be  blamed  than  the  surgeon.  The  condition  is  maintained  either 
by  recurring  slight  trauma,  or  by  some  remote  or  attenuated  infec- 
tion. Sometimes  hydrops  seems  to  be  chronic  from  the  start;  in 
such  cases  careful  search  should  be  made  for  any  site  of  infection 
which  may  maintain  a  toxemia  and  thus  interfere  with  joint  metab- 
olism. 


506 


DISEASES  OF  JOINTS 


The  joint  is  distended,  but  rarely  tense;  floating  of  the  patella 
mid  fluctuation  are  detected  easily;  and  no  signs  of  acute  inflammation 
or  constitutional  disturbance  are  present  (Fig.  542).  If  pain  is  entirely 
absent,  the  existence  of  a  Charcot  joint  should  be  suspected  (p.  502). 
The  patient  complains  of  weakness  and  insecurity  in  the  knee,  of  its 
tiring  easily,  of  a  feeling  of  fulness  and  discomfort  on  partial  flexion, 
and  of  inability  to  flex  the  joint  completely.    He  stands  usually  with 

the  knee  not  quite  fully  extended, 
though  passive  extension  may  produce 
no  discomfort.  There  may  be  a  mod- 
erate degree  of  villous  hypertrophy,  and 
"joint  mice"  may  develop;  indeed  such 
conditions  themselves  may  maintain  a 
state  of  chronic  synovitis  by  the  con- 
stant irritation  they  produce.  Increase 
in  the  pads  of  subpatellar  fat  is  not 
unusual  (see  Lipoma  Arborescens,  p. 
545);  and  the  neighboring  bursa?  may 
be  chronically  inflamed. 

Treatment. — Any  source  of  infection 
which  can  be  detected  should  be  cured, 
and  intestinal  putrefaction  and  toxemia 
should  be  overcome  if  present.  Locally, 
treatment  should  be  instituted  as  for 
acute  synovitis,  by  putting  the  joint 
at  absolute  rest  for  several  weeks. 
This,  with  moderate  uniform  pressure 
by  plaster  of  Paris  or  adhesive  strap- 
ping, may  cause  the  effusion  to  dis- 
appear. Counter-irritation  may  assist 
absorption.  It  may  now  be  possible 
to  detect  a  loose  cartilage  or  other 
form  of  "joint  mouse"  which  is  partly 
responsible  for  continuance  of  the  condi- 
tion. Rarely  aspiration  of  the  fluid  may 
be  employed  for  the  same  purpose,  and 
to  hasten  absorption;  it  should  be  followed  by  injection  of  2  per  cent, 
formalin  glycerin  solution.  I  once  did  arthrotomy,  finding  the  under 
surface  of  the  patella  and  opposing  femoral  cartilage  roughened,  and 
placed  a  drainage  tube  across  beneath  the  patella;  the  patient  recovered 
perfect  function  in  a  few  weeks,  and  in  the  eight  years  he  was  under 
observation  there  was  no  return  of  the  condition,  which  had  resisted 
conservative  treatment  for  months.  Such  a  plan  rarely  is  proper, 
because  the  disability  never  is  total,  and  the  disease  entails  no  risk 
to  life.  If  rest  and  immobilization  fail  to  secure  absorption  of  the 
fluid,  or  if,  as  is  usual,  effusion  recurs  when  joint  function  is  resumed, 
the  patient  may  be  allowed  to  walk  about  in  a  gypsum  case  or  brace; 
and  hot  and  cold  douches,  vigorous  massage  of  the  joint  and  leg  and 


Fig.  542. — Hydrops  articuli  of 
left  knee,  slight  of  right.  Gono- 
coccic  arthritis  of  left  knee  twelve 
years  ago.  Knee  always  swollen 
since.     Orthopaedic  Hospital. 


PERIARTHRITIS  507 

thigh  muscles  during  many  months,  and  elastic  compression  may 
bring  a  certain  measure  of  relief.  When  joint  mice  are  present,  they 
may  be  removed  by  arthrotomy,  in  the  hope  that  they  are  the  cause 
of  the  recurring  effusion.  It  is  rare  for  a  permanent  cure  to  be 
obtained. 

Intermittent  Hydrarthrosis  is  a  very  obscure  affection  of  joints, 
generally  believed  to  be  of  vaso-motor  origin.  The  effusion  occurs 
suddenly,  within  a  few  hours,  and  subsides  as  rapidly,  or  within  a 
day  or  two;  the  attacks  occur  at  more  or  less  regular  intervals,  perhaps 
daily  for  a  certain  portion  of  each  year,  or  every  few  months.  Almost 
any  joint  may  be  affected,  and  men  as  well  as  women  are  subject 
to  the  disease.     Treatment  is  purely  symptomatic. 

Periarthritis. — Periarthritis  is  a  vague  term  under  which  it  is 
convenient  to  group  various  subacute  or  chronic  periarticular  con- 
ditions until  their  true  pathology  can  be  determined.  These  lesions 
seem  to  be  more  frequently  a  cause  for  complaint  around  the  shoulder 
than  elsewhere,  though  they  occur  sometimes  in  other  joints.  They 
usually  are  caused  primarily  by  trauma  (sprains,  subluxations,  etc.), 
and  are  maintained  either  by  static  strain  (especially  in  the  sacro- 
iliac joint),  or  frequently  recurring  trauma.  The  condition  was 
mentioned  at  p.  316  and  421.  Codman  (1906)  drew  attention  to  the 
subdeltoid  bursa  as  the  main  factor  in  such  disability;  while  T.  T. 
Thomas  (1911)  thinks  cicatricial  contracture  of  the  axillary  portion 
of  the  capsule,  resulting  from  sprain  or  self-reduced  subluxation,  is  a 
more  frequent,  if  not  the  only  cause  of  the  condition  at  the  shoulder. 
The  neighboring  nerves  (axillary  plexus,  sacral  plexus  and  sciatic 
nerve)  may  be  involved  in  periarticular  adhesions,  and  thus  complicate 
the  case. 

Symptoms. — The  symptoms  are  pain  and  disability,  and  in  the 
shoulder  especially  limitation  of  abduction  and  external  rotation. 
Tendinous  or  bursal  crackling  often  is  present.  "Sprain  fracture" 
of  the  greater  tuberosity  of  the  humerus  sometimes  exists.  Each 
case  requires  careful  individual  study  to  determine  the  original 
cause,  and  if  possible  the  pathological  lesion  present.  Subdeltoid 
bursitis  is  characterized  by  tenderness  below  and  in  front  of  the 
acromion  when  the  arm  hangs  by  the  side,  this  tenderness  disappearing 
when  the  arm  is  abducted  and  the  bursa  disappears  beneath  the 
acromion;  in  chronic  cases  with  adhesions  abduction  is  impossible, 
and  the  diagnosis  is  more  difficult,  but  usually  there  are  no  physical 
signs  in  the  axilla.  Implication  of  nerves  is  recognized  by  symptoms 
of  neuritis,  and  sometimes  trophic  changes  in  the  fingers.  My  own 
experience  leads  me  to  coincide  with  Thomas's  views,  that  in  most 
cases  the  main  lesions  are  in  the  axillary  region  of  the  joint,  and  not 
in  the  subdeltoid  bursa. 

Treatment. — Massage,  passive  motion,  baking,  hot  air  douche, 
etc.,  may  all  be  tried.  Improvement  is  slow.  In  resistant  cases  the 
patient  should  be  etherized,  the  adhesions  forcibly  ruptured,  and 
the  arm  dressed  in  abduction.     Improvement  in  the  nutrition  of  the 


50S 


DISEASES  OF  JOINTS 


hand  may  follow  such  treatment.  If  it  be  certain  that  the  sub- 
deltoid bursa  is  the  seat  of  adhesions  which  cannot  be  ruptured  by 
manipulation,  the  bursa  may  be  opened  and  the  adhesions  cut  or  the 
bursa  excised.  Dissection  may  relieve  an  intractable  neuritis,  especially 
of  the  sciatic  nerve. 

Ankylosis. —  This  is  a  fixation  of  joints  by  intra-articular  adhesions. 
According  to  the  character  of  these  adhesions  ankylosis  is  classed 
as  fibrous  or  bony.  It  is  worth  while  to  repeat  here  again  that  limita- 
tion of  motion  from  extra-articular  causes  is  not  ankylosis;  it  has 
been  called  "false  ankylosis."  Thus  in  the  dystrophies  of  joints 
discussed  in  the  opening  paragraphs  of  this  chapter,  there  is  limitation 

of  motion,  but  not  ankylosis.     True  anky- 

^Hl     losis,  whether  fibrous  or  bony,    probably 

m  n^^v  ■      ;t'u;i.vs  's  the  result  of  infectious  arthritis 

or  of  trauma.  Complete  bony  ankylosis 
rarely  occurs  except  from  trauma,  most 
cases  of  bony  ankylosis  due  to  arthritis 
presenting  only  a  few  bands  or  processes 
of  bone  uniting  the  articulating  surfaces, 
the  remainder  of  the  joint  cavity  being 
filled  up  by  fibrous  adhesions.  If  only 
fibrous  ankylosis  is  present  it  usually  is 
possible  to  detect  a  few  degrees  of  motion 
if  the  joint  is  carefully  examined  under  an 
anesthetic.  It  is  important  to  remember 
the  best  positions  for  ankylosis,  since  when 
this  is  seen  to  be  inevitable,  the  surgeon 
must  enveavor  to  secure  the  least  dis- 
abling posture  for  the  patient  before  anky- 
losis becomes  complete:  for  the  shoulder  the 
humerus  should  be  in  abduction  about  70°, 
external  rotation  25°  to  30°  beyond  the 
sagittal  plane  and  flexion  45°;  the  elbow 
should  be  at  about  110°,  unless  both  elbows 
are  ankylosed,  when  one  should  be  at  60° 
or  less  so  that  the  patient  may  reach  his 
mouth;  the  wrist  should  be  in  hyperextension  (200°  to  210°);  the  hip 
in  abduction  (10°  to  15°),  flexion  (160°  to  170°),  and  very  slight  external 
rotation;  the  knee  straight  or  very  slightly  flexed  (never  hyperextended) ; 
and  the  ankle  at  75°  to  80°. 

Treatment. — The  treatment  of  ankylosis  in  tuberculous  arthritis  is 
considered  at  p.  529.  What  is  said  here  applies  to  ankylosis  due  to 
other  forms  of  infection  (pyogenic,  pneumococcic,  typhoid,  etc.), 
or  to  trauma.  If  ankylosis  occurs  with  the  limb  in  good  position,  no 
treatment  may  be  advisable,  especially  in  the  aged,  those  with  visceral 
disease,  etc.  A  stiff  hip  is  largely  compensated  for  by  mobility  in  the 
lumbar  spine;  a  stiff  elbow  may  be  useful  enough;  and  movements  of  the 
scapula  on  the  trunk  largely  compensate  for  ankylosis  in  the  scapulo- 


Fig.  543.  —  Brace  for  knee 
with  Stromeyer  screw,  to  pro- 
duce gradual  extension.  Ortho- 
paedic Hospital. 


ANKYLOSIS 


509 


humeral  joint;  but  almost  any  joint  which  is  in  bad  position  will  be 
improved  by  treatment.  With  very  few  exceptions,  however,  no  oper- 
ation should  be  undertaken  until  all  signs  of  active  disease  have  long 
since  subsided.  In  cases  of  fibrous  ankylosis,  where  the  disease  is  still 
subsiding,  the  use  of  weight  extension  or  of  elastic  compression  against 
a  splint,  or  of  a  splint  with  Stromeyer  screw  (Fig.  543),  may  secure  im- 
proved position;  and  in  cases  of  fibrous  ankylosis  and  false  ankylosis  in 
which  definitive  healing  has  occurred,  the  surgeon  may  make  attempts 


Fig.  544. — Instruments  used  in  excision  of  joints:  (1)  Blunt-pointed  resection  knife 
(2)  Periosteal  elevator.  (3)  Guide  for  Gigli  wire  saw  (4),  and  (5)  handles.  (6)  Chain 
saw.     (7)   Butcher's  saw  (1851),  the  blade  of  which  can  be  reversed,  so  as  to  cut  upward. 

to  secure  improved  position  by  rupture  of  adhesions  under  an  anes- 
thetic (arthrolysis  or  brisement  force),  always  making  movements  of 
flexion  before  those  of  extension  (to  avoid  damage  to  the  important 
periarticular  structures  in  the  flexures  of  joints),  and  seeking  to  rupture 
adhesions  by  abrupt  movements  of  small  excursion  rather  than  by  pro- 
longed or  violent  pressure.  The  joint  should  then  be  immobilized  in 
improved  position  until  inflammation  subsides,  when  gentle  passive 
movements  should  be  begun  and  active  use  encouraged.     While  such 


510 


DISEASES  OF  JOINTS 


measures  often  secure  improved  position  and  sometimes  a  moderate 
range  of  motion  in  eases  of  false  or  fibrous  ankylosis,  in  bony  anky- 
losis open  operation  is  required. 

If  it  is  not  desired  to  restore  motion  to  the  joint,  simple  osteotomy 
may  suffice  to  secure  good  position.  This  is  seldom  employed  except 
at  the  hip.  Here  the  neck  of  the  bone  may  be  divided  (Adams,  1871), 
but  as  this  often  is  distorted  by  disease,  subtrochanteric  osteotomy 
of  the  femur  (Gant,  1872),  is  preferable  (pp.  51 5,  530).  Excision  of  joints 
for  ankylosis  is  employed  to  correct  deformity  where  osteotomy  will 
not  suffice,  as  at  the  knee,  shoulder,  and  elbow.  In  the  latter  situa- 
tions a  movable  joint  is  sought,  but  at  the  knee  the  object  of  excision 
is  to  secure  ankylosis  in  full  extension,  the  most  useful  position. 
Excision  of  the  knee  is  done  without  an  Esmarch  band  by  a  transverse 


Fig.  545. — Excision  of  the  right  knee-joint.  The  ligamentum  mucosum  has  been 
divided,  exposing  the  crucial  ligaments.  The  saw  is  removing  a  section  from  the  con- 
dyles.    University  of  Pennsylvania. 

incision,  across  the  front  of  the  joint  from  the  posterior  edge  of  the 
base  of  one  condyle  to  that  of  the  other;  the  skin  is  dissected  up  until 
the  upper  border  of  the  patella  is  exposed,  and  the  quadriceps  tendon 
is  divided  at  its  insertion  into  the  patella;  the  knee-joint  is  acutely 
flexed,  and  the  intra-articular  ligaments  are  divided.  The  condyles 
of  the  femur  being  thus  cleared,  the  saw  is  applied  to  them  and  a  sec- 
tion about  half  an  inch  thick  is  removed,  not  at  right  angles  to  the  long 
axis  of  the  femur,  but  in  such  a  manner  that  the  posterior  internal 
portion  of  the  sawn  surface  shall  be  the  longest,  and  the  anterior 
external  the  shortest  (Fig.  545).  The  tibial  condyles  are  then  sawed 
across  at  right  angles  to  the  long  axis  of  the  leg,  but  somewhat  bevelled 
antero-posteriorly  so  as  to  correspond  to  the  section  of  the  femur.  The 
tibial  condyles  with  the  attached  patella  are  then  removed  in  one  mass. 
Barely  enough  of  the  femur  and  tibia  are  removed  to  allow  the 


EXCISION  OF  JOINTS 


511 


limb  to  come  straight;  the  posterior  ligaments  always,  and  the  lateral 
ligaments  whenever  possible,  are  left  intact.  The  periarticular  tissues 
are  sutured  with  chromic  catgut,  and  the  skin  is  closed  with  provision 
for  drainage  for  twenty-four  hours.  The  limb  is  dressed  in  plaster 
of  Paris  and  immobilization  continued  for  six  or  ten  weeks  until 
union  is  firm.  If  complete  bony  ankylosis  (in  bad  position)  is  present 
already,  it  is  sufficient  to  excise  a  wedge  of  bone  to  restore  the  axis 
of  the  limb  (Figs.  546  and  547).    In  all  cases  of  excision  of  the  knee, 


Fig.  546. — Ankylosis  of  knee  in  flexion, 
in  a  girl  of  twelve  years;  result  of  arthrec- 
tomy  for  tuberculosis  nine  years  pre- 
viously. (See  Fig.  547.)  Episcopal  Hos- 
pital. 


Fig.  547. — Result  of  cuneiform  resec- 
tion of  the  knee  shown  in  Fig.  546.  The 
epiphyseal  lines  have  been  carefully  pre- 
served.    Episcopal  Hospital. 


the  limb  should  be  supported  by  a  brace  for  a  year  afterwards.  The 
elbow  is  excised  through  a  straight  posterior  incision  splitting  the 
triceps  muscle  near  the  inner  border  of  the  olecranon,  and  carefully 
separating  its  tendinous  expansion  from  the  olecranon.  Injur}'  of  the 
ulnar  nerve  should  be  avoided;  it  is  most  liable  to  injury  just  below 
the  level  of  the  joint  close  to  the  inner  border  of  the  olecranon.  After  the 
lateral  ligaments  have  been  divided  (Fig.  548)  the  joint  may  be  luxated. 
Enough  bone  is  removed  (leaving  the  radial  insertion  of  the  biceps) 


512 


DISEASES  OF  JOINTS 


to  ensure  a  false  joint  being  established;  a  space  of  at  least  four 
centimeters  should  exist  between  the  humerus  and  bones  of  the  fore- 
arm, to  ensure  free  motion   (Figs.  549  and  550.)     The  limb  is  im- 


Fig.  548. — Excision  of  the  elbow-joint.  The  joint  has  been  opened  posteriorly  and 
the  condyles  of  the  humerus  exposed.  Above  is  seen  the  olecranon;  just  below  it  the 
trochlear  surface  of  the  humerus.  The  retractors  pull  aside  the  split  triceps  and  the 
scissors  are  cutting  the  internal  lateral  ligament.     University  of  Pennnsylvania. 


Fig.  549. — Result  of  excision  of  elbow  for  anky 
losis  following  fracture.     Episcopal  Hospital. 


Fig. 


550. — Same  patient  as  F'n 
549,  elbow  extended. 


EXCISION  OF  JOINTS 


513 


mobilized  only  until  the  soft  parts  heal;  active  use  is  then  encouraged. 
Return  of  function  depends  largely  on  preservation  of  the  periosteum 
into  which  the  triceps  inserts,  and  its  fibrous  expansion  over  the  radius. 
The  shoulder  is  excised  through  an  anterior  incision  in  the  hollow  be- 
tween the  coracoid  and  acromion  processes,  thus  avoiding  injury  to 
the  branches  of  the  circumflex  nerve.  The  long  tendon  of  the  biceps 
is  pushed  to  one  side.  The  capsule  is  opened  as  in  shoulder-joint 
amputations,  and  the  muscles  inserted  into  the  tuberosities  are  divided 
as  there  described  (Fig.  551.)  Usually  the  section  of  the  humerus  is 
made  through  the  surgical  neck ;  but  it  is  better  to  remove  more  bone 
from  the  glenoid  than  from  the  humerus,  since  restoration  of  function 


Fig.  551. — Excision  of  shoulder  by  anterior  longitudinal  incision.  After  division  of 
the  capsule  and  the  muscles  attached  to  the  tuberosities  the  arm  is  allowed  to  hang 
over  the  edge  of  the  tab'e;  this  causes  the  head  of  the  humerus  to  project  from  the 
wound.     University  of  Pennsylvania. 


depends  largely  on  the  preservation  of  the  muscular  insertions  in  the 
latter.  After-treatment  is  the  same  as  in  excision  of  the  elbow.  In 
all  these  excisions,  it  is  well,  if  possible,  to  open  up  the  line  of  the  old 
articulation  first,  by  breaking  adhesions  and  sawing  across  bridges  of 
bone,  and  then  to  remove  from  the  bone  ends  so  much  as  is  necessary. 
Attempts  to  excise  a  joint  in  one  block,  except  by  experienced  sur- 
geons, result  in  the  removal  of  too  much  or  too  little  bone.  Excision 
of  the  wrist  seldom  is  required ;  in  most  cases  an  erasion  (p.  529)  suffices. 
If  formal  excision  is  done,  the  best  incision  is  that  of  Mynter  (1894), 
splitting  the  dorsum  of  the  hand  between  the  index  and  middle 
fingers.  Ankylosis  is  the  desired  result. 
Arthroplasty  is  discussed  at  p.  252. 
33 


514  DISEASES  OF  JOINTS 

SPECIAL  INFECTIONS  OF  THE  JOINTS. 

The  special  infections  of  the  joints  usually  can  be  differentiated 
clinically  from  pyemic  infections,  and  from  each  other,  but  bacterio- 
logical study  of  the  joint  fluids  or  capsule  may  be  necessary.  Pyemic 
infections  of  joints  are  referred  to  at  p.  71. 

Pneumococcic  Infection  usually  is  a  complication  of  pneumonia 
(70  per  cent,  of  cases),  but  may  occur  from  other  sources,  especially 
otitis  media.  The  knee  and  shoulder  are  most  often  attacked.  There 
is  purulent  effusion,  and  the  signs  of  acute  arthritis  are  present. 
Treatment  consists  in  aspiration  of  the  fluid  and  injection  of  2  per  cent, 
formalin-glycerin  solution,  and  use  of  weight  extension.  Arthrotomy 
and  drainage  should  be  done  if  symptoms  are  severe  or  persist. 
The  mortality  is  about  33  per  cent.  (K.  Bulkley,  1914).  Ankylosis 
is  not  unusual,  but  formation  of  sinuses  is  rare. 

Gonococcic  Infection  usually  is  secondary  to  a  gonococcic  urethritis 
or  its  local  complications.  It  occurs  in  less  than  2  per  cent,  of 
cases,  and  mostly  in  the  male  sex;  almost  invariably  the  joint  con- 
dition appears  in  the  end  of  the  third  week  (eighteenth  to  twenty- 
second  day)  after  the  onset  of  gonorrhea.  Diagnosis  in  obscure  cases 
may  be  aided  by  the  complement-fixation  test.  The  polyarticular  form 
is  rheumatic  (i.  e.,  synovial)  in  character,  somewhat  resembling 
acute  rheumatic  arthritis;  but  the  monarticular  form  is  more  like  a 
septic  arthritis.  In  the  former  the  small  joints  of  the  hands  and  feet 
are  oftenest  affected;  sometimes  the  sterno-clavicular  joint.  In  the 
monarticular  form  the  knee,  ankle,  wrist,  and  elbow  are  oftenest 
invaded.  The  joints  become  extremely  painful,  swollen,  red,  and 
doughy  to  the  touch.  There  is  not  much  effusion.  Endocarditis 
is  an  occasional  complication.  Spontaneous  fistulization  is  rare. 
After  gonococcic  arthritis  the  joints  are  left  in  a  more  or  less  damaged 
and  sometimes  seriously  deformed  state.  Bony  ankylosis  is  not 
unusual. 

Treatment. — If  rest  of  the  affected  joints  (the  patient  always  being 
confined  to  bed,  and  the  primary  infection  receiving  proper  attention) 
does  not  secure  marked  improvement  within  forty-eight  hours,  the 
joints  should  be  opened,  and  irrigated  with  saline  or  formalin-glycerin 
solution,  and  closed  without  drainage.  There  is  too  little  effusion, 
as  a  rule,  for  mere  aspiration  and  injection  to  be  efficient.  Usually 
the  disease  is  much  shortened  by  joint  irrigation;  under  conservative 
measures  the  joints  may  remain  acutely  painful  for  weeks,  and  the 
patient's  health  often  is  gravely  affected,  hectic  fever  and  emaciation 
developing.  Vaccine  therapy  is  of  considerable  value.  Fuller  (1905) 
has  proposed  and  practised  drainage  or  extirpation  of  the  seminal 
vesicles  which  some  regard  as  the  focus  which  maintains  the  infection. 
They  are  accessible  by  the  suprapubic  extra-peritoneal  route. 

Typhoid  Arthritis  occurs  during  or  after  convalescence  from  typhoid 
fever,  usually  about  the  third  or  fourth  week  of  the  disease.  Its 
development  may  be  overlooked,  owing  to  the  patient's  apathetic 


SPECIAL  INFECTIONS  OF  THE  JOINTS 


515 


state.  The  hip  is  most  often  affected  (Figs.  552  and  553);  suppura- 
tion and  sinus  formation  are  not  unusual  (perhaps  from  mixed  infec- 
tion), though  as  in  pneumococcic  and  gonococcic  arthritis  ankylosis 
may  follow  without  frank  suppuration.  Pathological  luxation  may 
occur.  Typhoid  spondylitis  (p.  662)  sometimes  is  seen,  though  a  true 
inflammation  of  the  vertebral  joints  is  much  rarer  than  a  periarticular 
fibrosis. 


Fig.  552. — Post-typhoid  ankylosis  of 
left  hip,  in  a  lad  of  sixteen  years. 
Dr.  Harte's  case.  (See  Fig.  553.)  Ortho- 
paedic Hospital. 


Fig.  553.  —  Result  of  subtrochanteric 
osteotomy  of  left  femur  for  bony  ankylosis 
in  bad  position.  (See  Fig.  552.)  Ortho- 
paedic Hospital. 


Metastatic  Arthritis. — In  addition  to  these  special  infections  of 
joints,  and  to  tuberculous  and  syphilitic  joint  diseases,  which  are  con- 
sidered at  p.  519  and  545,  there  are  a  number  of  other  systemic  infec- 
tions, the  etiological  organisms  of  which  are  not  known  in  all  cases, 
but  which  sometimes  are  accompanied  or  followed  by  inflammation 
of  one  or  more  joints,  and  in  which  it  is  very  evident  that  the  general 
infection  is  responsible  for  the  local  inflammation,  either  by  direct 
action  of  its  bacteria,  or  through  the  toxins  derived  from  these  microbes. 

1.  We  may  recognize  acute  or  subpyemic  infections,  some  of  them 


510  DISEASES  OF  JOINTS 

having  a  more  or  less  evident  etiology  and  symptomatology  (arthritis 
and  scarlet  fever,  influenza,  dysentery,  etc.);  while  in  others,  such  as 
"acute  articular  rheumatism,"  the  joint  infection  itself  seems  almost 
to  constitute  the  disease.  Acute  rheumatic  arthritis  probably  is  a  form 
of  pyemia.  Immediate  removal  of  the  pharyngeal  tonsils,  thought 
by  some  to  be  the  portal  of  infection,  has  been  adopted  in  a  few  cases. 
Or  the  surgeon  may  open,  irrigate,  and  close  the  first  joint  affected;  or 
aspiration  and  injection  with  formalin-glycerin  solution  (2  per  cent.) 
may  be  done. 

Probably  the  form  of  acute  metastatic  arthritis  most  often  encoun- 
tered is  that  following  infections  of  the  pharynx,  naso-pharynx.,  or  tonsils. 
The  joint  manifestations  occur  so  long  (several  weeks)  after  the  primary 
lesion  has  healed  that  their  inter-relation  usually  is  overlooked.  The 
patients  come  to  the  surgeon  with  bony  ankylosis,  and  tell  him  their 
physician  has  been  treating  them  for  rheumatism.  The  history  is 
that  very  soon  after  exposure  to  cold  or  wet,1  sudden  pain  developed 
in  one  or  more  joints;  probably  a  chill  occurred;  the  joint  became 
swollen,  red,  and  tender;  the  patients  lay  in  bed  a  long  time  in  one 
position;  and  finally  when  in  the  course  of  several  weeks  the  acute 
symptoms  subsided,  one  or  more  joints  were  found  to  be  stiff,  and 
have  remained  so  since.  A  skiagraph  will  show  bony  ankylosis. 
Now,  acute  rheumatic  arthritis  does  not  cause  ankylosis,  its  symptoms 
are  rapidly  relieved  by  salicylates,  and  the  disease  does  not  last  more 
than  two  or  three  weeks. 

These  acute  metastatic  joint  infections  should  be  treated  by  weight- 
extension  (to  prevent  deformity  and  if  possible  ankylosis),  by  aspira- 
tion of  the  joint  contents  (to  relieve  pressure  on  the  synovial  mem- 
brane thus  preventing  its  destruction),  and  by  injection  of  10  to  15  ex. 
of  a  2  per  cent,  formalin-glycerin  solution  (to  sterilize  the  joint).  This 
injection  may  have  to  be  repeated  once  or  twice  after  intervals  of  a 
few  days  (Murphy,  191:;). 

2.  Chronic  or  Cryptogenous  Infections. — There  is,  moreover,  a  still 
more  obscure  group  of  joint  diseases,  which  clinically  give  every  evi- 
dence of  being  infectious,  but  the  true  pathogenesis  of  which  has  not 
been  established  from  a  bacteriological  standpoint.  These  may  be 
called  cryptogenous  injections  of  joints,  and  include  various  "rheuma- 
toid" conditions,  which  clinically  resemble  infectious  as  distinguished 
from  dystrophic  arthritis  (p.  493).  Among  these,  chronic  rheumatic 
arthritis,  a  disease  whose  existence  I  do  not  doubt,  holds  an  important 
place;  by  it  I  understand  the  damaged  condition  of  joints  which  may 
persist  after  one  or  several  attacks  of  "acute  articular  rheumatism;" 
on  such  a  joint  may  be  grafted,  as  on  to  any  joint  or  set  of  joints  whose 
resistance  is  below  par,  dystrophic  lesions.  I  believe  Fig.  554  repre- 
sents such  a  condition.  Stills  Disease  (1897),  a  chronic  polyarticular 
affection  of  young  childhood,  resembling  atrophic  arthritis  in  many 
respects,  and  accompanied  by  enlargement  of  the  lymph  nodes  and 

1  This  is  to  be  regarded  merely  as  the  localizing  cause  of  the  joint  lesions.  The 
infection  which  occurred  two  or  three  weeks  previously  is  the  original  cause. 


METASTATIC  ARTHRITIS 


517 


spleen,  and  involvement  of  the  cervical  spine,  probably  belongs  among 
the  cryptogenous  infections.     So  does  the  tuberculous  rheumatism  of 


Fig.  554. — Chronic  rheumatic  arthritis;  age  fifty  years;  had  acute  rheumatic 
arthritis  as  child  and  as  girl.     Orthopaedic  Hospital. 


Fici.  555. — Tuberculous  rheumatism  in  a  girl  of  five  years.  Acute  onset  in  left  ankle, 
some  weeks  after  an  attack  of  scarlatina.  Six  months  later  left  knee,  wrist,  and  shoulder 
became  similarly  affected;  reacted  to  tuberculin.  Photographed  one  year  after  onset. 
(See  Fig.  556.)     Orthopaedic  Hospital. 


518 


DISEASES  OF  JOINTS 


Poncet  (1903),  which  is  a  subacute  polyarticular  infection,  somewhat 
resembling  in  onset  "acute  articular  rheumatism,"  but  probably  due 
to  endogenous  toxins  of  tubercle  bacilli  (Figs.  555  and  55G).  In  this 
group  of  cryptogenous  infections  also  belong  certain  cases  of  arthritis 


Fig.  556. — Patient  shown  in  Fig.  555,  one  year  later.  Normal  extension  in  left 
wrist.  Knee  still  in  plaster  of  Paris,  and  four  years  later  not  yet  quiet.  Orthopaedic 
Hospital. 

which  cease  to  trouble  the  patient  when  he  is  cured  of  some  source  of 
infection  which  may  have  been  neglected  for  years;  such  are  dental 
caries,  pyorrhea  alveolaris;  sinus  diseases;  affections  of  the  tonsils; 
empyema  thoracis  (Fig.  557);  affections  of  the  lungs  (here  belongs 
pulmonary  osteo-arthropathy) ,  intestines,  appendix;  genito-urinary  dis- 


Fio.  557. — Pulmonary  osteoarthropathy.     Clubbed  fingers  four  years  after  operation 
for  empyema  (unhealed).     Age  ten  years.     Children's  Hospital. 


eases  in  both  sexes,  especially  chronic  semino-vesiculitis  or  prostatitis 
in  the  male,  and  cervical  lacerations  in  the  female,  etc.  Cases  of 
joint  disease  concerned  with  one  or  more  of  the  above  infections  are 
constantly  being  seen,  and  are  recognized  by  intelligent  physicians. 


TUBERCULOSIS  OF  JOINTS  519 

In  many  cases  the  infecting  organism  may  be  recovered  from  the 
urine;  and  treatment  by  vaccines  may  prove  curative. 

In  chronic  rheumatoid  conditions  always  look  for  a  source  of 
infection. 

Tuberculosis  of  Joints.1 — Pathology. — In  tuberculous  arthritis  the 
primary  lesion  in  almost  all  cases,  especially  in  children,  is  in  the 
adjacent  bone,  and  the  synovial  membrane  lining  the  joint  cavity 
is  invaded  only  secondarily.  This  was  first  definitely  shown  by 
Nichols,  of  Boston,  in  1898.  The  bacilli  reach  the  bone  ends  through 
the  blood-stream,  presumably  from  a  preexisting  focus  in  the  bronchial 
or  mesenteric  lymph  nodes;  and  they  lodge  in  the  region  of  the  epiphy- 
seal cartilage  rather  than  in  the  diaphysis  of  the  bone  for  the  ana- 
tomical reasons  stated  at  p.  480.  The  disease  begins  on  one  side  or 
other  of  the  epiphyseal  cartilage.  An  additional,  and  perhaps  a  better 
reason  for  this  localization  of  the  bacilli  is  suggested  by  Ely  (1911): 
he  recalls  the  well  known  fact  that  tubercle  bacilli  flourish  where 
red  marrow  exists  (as  in  the  epiphyses  of  growing  bones),  whereas 
bone  which  contains  yellow  marrow  (adult  bones  throughout,  and 
the  diaphyses  of  juvenile  bones)  is  almost  immune  to  tuberculous 
invasion;  he  also  suggests  that  the  immunity  of  cartilage  and  fascia 
to  tuberculous  invasion  is  due  to  the  fact  that  only  in  connective 
tissues  which  have  epithelial,  epithelioid,  or  lymphoid  cells,  do  tubercle 
bacilli  find  a  suitable  soil  for  development,  and  that  in  this  way  the 
marked  affinity  of  tuberculosis  for  synovial  membrane  is  to  be  ex- 
plained. This  theory  of  Ely's  also  explains  why  primary  synovial 
tuberculosis  is  so  much  less  unusual  in  adults  than  in  children,  since 
the  bones  of  the  former  do  not  afford  a  suitable  soil  for  the  develop- 
ment of  tuberculosis,  owing  to  the  absence  of  red  marrow. 

In  tuberculosis  of  an  epiphysis  the  lesion  exists  in  the  marrow, 
the  cells  of  this  structure  being  grouped  around  the  invading  bacilli 
in  the  form  of  histological  tubercles;  the  bony  trabecular  are  then 
destroyed,  the  center  of  the  tuberculous  focus  undergoes  caseation, 
and  caries  of  the  bone  is  said  to  exist;  if  actual  liquefaction  occurs  a 
cold  abscess  of  bone  is  formed.  The  entire  bone  end  is  the  seat  of 
a  rarefying  osteitis,  the  bony  trabecular  being  much  decreased  in 
size  and  strength,  while  the  marrow  spaces  are  increased.  Formation 
of  sequestra  is  rather  unusual;  when  found  they  are  small,  and  typic- 
ally worm-eaten  in  appearance.  Often  there  is  a  zone  of  sclerosed 
bone  immediately  around  the  sequestrum  or  the  central  caseous 
area,  while  outside  of  the  sclerotic  bone  the  rarefying  osteitis,  above 
described,  continues.  Caries  Sicca  is  a  term  used  by  Volkmann 
(1867)  to  describe  a  rare  form  of  joint  disease  now  recognized  as 
tuberculous,  which  is  seen  oftenest  in  the  shoulder  and  in  which 
gradual,  quiet,  fibrous  ankylosis  occurs,  without  swelling  or  other 
evidences  typical  of  tuberculous  arthritis. 

xThe  tuberculous  nature  of  these  diseases  was  first  clearly  demonstrated  by 
Volkmann,  in  a  classical  paper  published  in  1879. 


:>2o 


DISEASES  OF  JOINTS 


Fig.  558. — Head  and  neck  of  femur 
excised  for  tuberculosis.  Note  "pepper- 
pot"  appearance  of  cartilage  covering  head 
of  femur;  pathological  fracture  of  neck:  and 
small  sequestrum  below.  Children's  Hos- 
pital. 


The  articular  cartilage   resists  for  ;i   long  time   invasion   by  the 
spreading  tuberculous  process,  and  when  the  joint  finally  is  entered 

it  is  more  often  at  the  site  of 
attachment  of  the  capsule  than 
in  the  center  of  the  articular 
cartilage.  But  as  the  disease 
progresses  the  articular  cartilage 
is  gradually  covered  in  by  the 
tuberculous  granulation  tissue  or 
"pannus,"  and  is  perforated  in 
numerous  places,  giving  it  (Fig. 
558)  a  typical  sieve-like  (Volk- 
mann,  1882)  or  "pepper-pot"  ap- 
pearance; and  in  advanced  cases 
the  cartilage  may  be  entirely  de- 
stroyed. 

Before  actual  tuberculous  inva- 
sion of  the  joint  cavity,  there  may 
be  slight  serous  synovitis  with 
effusion,  from  irritation  due  to  the 
focus  in  the  neighboring  bone  end. 
When  the  synovia  has  once  been 
invaded,  or  in  the  rare  cases  of  primary  synovial  disease,  the  tuber- 
culous process  spreads  rapidly  throughout  the  joint,  attacking  and 
perhaps  destroying  the  ligaments,  reach- 
ing out  along  adjacent  tendon  sheaths 
and  bursa? ,  and  causing  a  pulpy,  gela- 
tinous hyperplasia  of  all  the  serous 
tissues  attacked  (gelatinous  arthritis, 
J.  Ashhurst,  Jr.  1871).  Usually  there 
is  very  little  effusion,  though  "tuber- 
culous hydrops"  occasionally  occurs  |  Fig. 
559).  Either  by  condensation  of  fibri- 
nous flakes,  or  by  detachment  of  the 
tips  of  the  villous  synovial  fringes,  so- 
called  "rice-bodies"  or  "melon-seed 
bodies"  may  develop  in  tuberculous 
joints.  By  most  authorities  these  are 
regarded  as  highly  characteristic  of  the 
tuberculous  nature  of  the  joint  lesions: 
tubercle  bacilli  frequently  have  been 
found  within  the  rice-bodies,  and  their 
inoculation  into  susceptible  animals 
causes  generalized  tuberculosis. 

If  the  tuberculous  process  extends  to 
the  skin  surface,  and  a  cold  abscess  of 
bone  discharges  itself  through  a  sinus, 
secondary  infection  with  pyogenic  cocci 


Fig.  559. — Tuberculous  hydrops 
of  right  knee.  Age  eight  years. 
Duration  six  months.  For  persist- 
ence of  symptoms,  excision  of  knee  ' 
was  done  five  years  later.  (Dr. 
Dickson's  case.)  Orthopaedic 
Hospital. 


CLINICAL  COURSE  OF  TUBERCULOUS  ARTHRITIS         521 

is  extremely  apt  to  occur.  Before  such  secondary  invasion  the  walls 
of  a  sinus  communicating  with  a  tuberculous  focus  are  not  themselves 
the  seat  of  tuberculosis;  but  when  secondary  infection  is  present  the 
connective  tissue  which  forms  the  walls  of  such  a  sinus  are  studded 
with  tubercles  (Ely,  1911).  Secondary  invasion  with  pyogenic  cocci 
may  occur  through  the  blood-stream  before  any  sinus  forms;  such 
a  complication  is  apt  to  hasten  the  disintegrating  process  and  encourage 
formation  of  sinuses. 

Healing  occurs  by  the  encapsulation  of  the  tuberculous  focus  or  its 
replacement  by  fibrous  tissue.  If  the  joint  cavity  has  been  invaded 
this  implies  more  or  less  firm  fibrous  ankylosis.  In  most  cases 
the  tuberculous  process  merely  becomes  latent,  and  is  prone  to  become 
active  again  if  the  joint  is  subjected  to  unusual  strain,  or  if  the  gen- 
eral health  becomes  impaired,  particularly  by  the  development  of 
pulmonary  tuberculosis. 

Clinical  Course  and  Symptoms. — Joint  tuberculosis  is  much  more 
frequent  in  children  than  in  adults,  arising  especially  during  the 
first  decade  of  life.  The  spinal  joints  are  those  most  often  affected; 
the  knee  and  hip  come  next  in  order  of  frequency;  while  the  joints 
of  the  foot,  elbow,  and  wrist  are  more  frequently  diseased  than  the 
shoulder.  In  about  one-third  of  the  cases  in  children  a  history  of 
traumatism  can  be  obtained,  two  or  three  weeks  previous  to  the 
onset  of  joint  symptoms;  and  this  generally  is  regarded  as  having  a 
distinct  etiological  relation  to  the  development  of  the  disease.  But 
it  must  be  remembered  that  nearly  all  children  sustain  slight  joint 
injuries,  yet  comparatively  few  develop  tuberculous  arthritis;  so 
that  it  is  necessary  to  assume  a  predisposition  to  tuberculosis  and 
the  existence  of  a  primary  focus  elsewhere  in  the  body.  The  injury 
which  precedes  the  tuberculous  joint  symptoms  rarely  is  severe; 
fractures  scarcely  ever  are  followed  by  tuberculosis,  and  fractures 
in  the  tuberculous  heal  normally.  Two  explanations  are  offered  for 
this:  one  is  that  the  more  severe  injury  arouses  better  defensive 
action  on  the  part  of  the  patient;  the  other  is  that  severe  lesions  require 
careful  and  prolonged  treatment,  and  healing,  therefore,  is  more  apt 
to  occur  than  after  a  trivial  injury  which  often  is  neglected. 

Among  the  earliest  subjective  symptoms  of  tuberculous  arthritis 
are  disability  and  pain.  The  joint  is  used  less,  the  joint  is  "favored," 
and  it  gives  evidence  of  being  more  easily  tired  than  the  normal 
joint.  Stiffness  present  on  getting  out  of  bed  in  the  morning  may 
wear  away  during  the  day;  but  toward  evening  the  joint  again 
becomes  disabled,  and  this  is  evidenced  by  slight  limp,  and  complaints 
of  pain.  Pain  may  be  almost  absent  except  when  the  joint  is  used; 
but  frequently  a  joint  which  is  painless  when  the  child  is  awake  will 
trouble  it  at  night,  causing  restlessness,  and  on  falling  asleep  and 
relaxing  its  muscles  the  child  will  experience  "starting  pains''  which 
will  rouse  it  momentarily  from  sleep  with  a  "night-cry."  Instead 
of  pain  being  felt  at  the  diseased  joint,  it  may  be  referred  to  the 
peripheral  distribution   of   the   nerve   supplying  the  joint:   thus   in 


522  DISEASES  OF  JOINTS 

tuberculous  spondylitis  pain  frequently  is  present  in  the  epigastrium 
(intercostal  nerves),  and  in  tuberculosis  of  the  hip  pain  is  referred 
to  the  knee  (obturator  nerve). 

Examination  of  the  diseased  joint  at  this  early  stage  shows  slight 
but  persistent  muscular  spasm.  The  muscles  surrounding  a  joint 
are  supplied  by  the  same  nerve  that  supplies  the  joint,  and  irritation 
of  the  joint  causes  reflex  irritation  of  the  adjacent  muscles  (Hilton's 
law,  18G3).  The  joint  may  be  held  absolutely  rigid  by  the  patient, 
but  in  the  earliest  stages  the  most  that  can  be  detected  is  limitation 
of  motion  in  all  directions:  there  is  neither  full  extension,  flexion, 
abduction,  adduction,  nor  rotation;  and  forcing  any  of  these  motions 
causes  pain.  Comparison  with  movements  of  the  corresponding 
unaffected  joint  is  imperative.  The  joint  is  held  in  the  most  com- 
fortable position  and  is  consistently  protected  by  the  patient:  a 
sore  wrist  or  elbow  is  supported  by  the  other  hand,  and  if  the  hip  or 
knee  is  involved  the  sound  foot  may  be  put  under  the  ankle  of  the 
diseased  limb  and  be  used  as  a  splint  to  prevent  motion  in  the  painful 
joint. 

There  is  tenderness  to  palpation  directly  over  the  joint,  and  per- 
sistent tenderness  of  a  bone  end  with  evidences  of  articular  irritation 
is  a  valuable  sign.  Unless  the  disease  is  advanced,  or  primarily 
synovial  in  origin,  there  is  rarely  much  thickening  of  the  capsule  or 
synovial  effusion.  In  superficial  joints  (knee,  elbow,  ankle)  more 
or  less  heat  usually  is  appreciable,  but  in  the  hip  this  seldom  can  be 
detected.  Muscular  atrophy,  an  evidence  of  disuse,  is  a  valuable 
confirmatory  sign  of  tuberculous  arthritis ;  in  early  stages  it  sometimes 
can  be  detected  only  by  measurement,  but  in  later  stages,  where 
articular  thickening  is  present  and  accentuates  the  atrophy,  it  is 
apparent  at  a  glance  (Fig.  586). 

With  these  local  signs  there  is  seldom  much  constitutional  reaction. 
The  temperature  may  be  raised  1°  or  2°  in  the  evening,  and  loss  of 
appetite  and  malaise  may  be  present ;  but  there  is  no  acute  inflamma- 
tory state  such  as  is  seen  in  cases  of  septic  arthritis. 

As  the  disease  progresses,  the  joint  thickening  increases,  being  of  a 
doughy,  boggy  consistency,  and  typically  spindle-shaped  in  outline. 
The  skin  is  pallid,  and  the  affection  well  deserves  the  name  "white 
swelling"  first  applied  to  it  in  1734  by  Wiseman.  Spastic  contraction  of 
the  surrounding  muscles  passes  into  true  contractures,  which  will 
maintain  deformity  even  if  ankylosis  is  absent.  Progressive  joint  dis- 
integration may  lead  to  partial  or  complete  dislocation;  and  this  usually 
is  attended  by  relief  from  pain.  Finally,  by  rupture  of  cold  abscesses, 
sinuses  may  develop,  and  usually  this  complication  is  quickly  followed 
by  secondary  infection,  resulting  in  hectic  fever,  and  the  gradual  but 
progressive  decline  of  the  patient's  general  health. 

Diagnosis. — Symptoms  of  subacute  arthritis  in  a  child,  from  no 
apparent  cause,  or  following  slight  injury,  and  without  marked 
constitutional  reaction,  but  persisting  in  spite  of  temporary  rest, 
always  should  excite  a  suspicion  of  tuberculosis.     This  suspicion  is 


SYMPTOMS  OF  TUBERCULOUS  ARTHRITIS  523 

strengthened  by  a  family  history  of  tuberculosis,  either  pulmonary 
or  osseous,  and  is  made  nearly  positive  if  there  is  persistent  elevation 
of  temperature  of  1°  or  2°,  if  the  tuberculin  tests  (p.  79)  are  posi- 
tive, and  if  there  is  no  leukocytosis.  Skiagraphic  examination  rarely 
will  reveal  any  bony  focus  so  early  in  the  disease  as  to  be  of  much 
value  in  doubtful  cases,  but  a  squaring  of  the  epiphyses,  particularly 
at  the  knee,  is  regarded  as  characteristic  of  tuberculosis. 

A  sprain  will  cease  to  cause  acute  symptoms  if  the  joint  is  put  to 
rest  for  two  or  three  weeks;  but  a  tuberculous  arthritis  always  will 
be  roused  to  activity  if  joint  function  is  resumed  in  so  short  a  time. 
A  septic  arthritis  is  more  violent  in  its  onset,  is  attended  by  much 
more  constitutional  disturbance,  and  progresses  to  early  suppuration 
and  joint  disintegration;  its  course  is  run  in  days  and  weeks,  while 
that  of  a  tuberculous  arthritis  extends  over  months  and  years.  Acute 
rheumatic  arthritis  is  in  most  cases  a  polyarticular  affection,  is  char- 
acterized by  high  temperature,  cardiac  or  pleural  complications, 
hyperleukocytosis,  and  marked  local  inflammatory  reaction.  It  is 
rare  in  young  children.  In  syphilitic  arthritis  other  signs  of  syphilis 
nearly  always  can  be  detected. 

A  positive  diagnosis  of  tuberculosis  always  can  be  made  if  tubercle 
bacilli  can  be  found  in  the  synovial  membrane,  rice-bodies,  joint- 
fluid,  etc.,  or  if  inoculation  with  these  substances  causes  tuberculosis 
in  a  susceptible  animal. 

Prognosis. — The  most  favorable  cases  are  those  of  apparent  osseous 
origin  in  children,  in  which  efficient  treatment  is  instituted  before 
evidences  of  invasion  of  the  synovia  are  demonstrable,  and  in  which 
the  symptoms  are  so  slight  as  scarcely  to  warrant  a  positive  diagnosis. 
These  are  the  cases  in  which  patients  recover  with  joints  which  are 
to  all  intents  and  purposes  normal.  After  joint  invasion  is  once 
demonstrable,  and  in  cases  primarily  synovial,  the  most  that  can  be 
hoped  for  is  recovery  with  more  or  less  impairment  of  motion;  and 
the  more  firm  the  ankylosis  the  less  apt  will  the  patient  be  to  have 
recurrence  of  the  disease.  After  secondary  infection  the  prognosis 
is  gloomier  both  as  to  function  and  life;  and  in  adults  all  forms  of 
tuberculous  arthritis  are  much  more  serious  than  in  children.  In 
general  terms  it  may  be  stated  that  from  one-third  to  one-half  of 
patients  with  tuberculous  arthritis  die  as  a  result  of  their  joint  lesions; 
few  indeed  as  a  direct  consequence  (then  mostly  from  hectic,  amyloid 
degeneration  of  the  viscera,  etc.),  but  many  from  tuberculous  menin- 
gitis, phthisis,  or  some  intercurrent  malady  from  which  healthier 
persons  would  have  recovered.  In  cases  ending  in  apparent  recovery, 
which  often  is  merely  latency  of  the  tuberculous  process,  the  course 
of  treatment  must  last  from  one  to  five  years  or  longer;  and  other 
patients  must  continue  treatment  until  death  removes  them  from 
the  surgeon's  care. 

Treatment. — The  constitutional  treatment  of  surgical  tuberculosis 
was  discussed  at  p.  80;  its  value  in  tuberculous  arthritis  is  inesti- 
mable, and  never  should  be  forgotten.    The  most  efficient  local  treat- 


524  DISEASES  OF  JOINTS 

mi nt  frequently  is  powerless  to  check  the  disease;  and  sometimes 
constitutional  treatment  alone  is  able  to  restore  a  patient  to  health. 
The  surgeon  must  not  overlook  the  fact  that  it  is  better  to  have  a 
healthy  body  with  a  stiff  or  deformed  joint,  than  to  have  a  straight 
and  comely  joint  without  a  body  capable  of  sustaining  life.  If  the 
general  health  is  good,  joint  function  can  be  restored  subsequently 
by  an  orthopedic  operation.  Every  hospital  should  have  an  open 
air  ward  or  at  least  a  porch  available  for  tuberculous  joint  cases, 
where  the  advantages  of  constitutional  and  local  treatment  may  be 
combined  for  those  most  requiring  such  care. 

Local  treatment  may  be  summed  up  almost  in  one  word:  Rest. 
It  is  not  known  definitely  how  this  acts,  but  a  plausible  theory  is 
suggested  by  Ely  (1911) :  he  contends  that  cure  is  effected  by  abolish- 
ing joint  function,  because  thus  both  red  marrowr  and  synovia  become 
atrophic  and  in  the  case  of  ankylosis  entirely  disappear;  and  where 
they  are  not,  tubercle  bacilli  cannot  exist. 

There  are  two  chief  methods  by  which  joint  rest  is  obtained: 
fixation  and  traction.  Fixation  is  secured  by  the  use  of  splints,  plaster 
cases,  braces,  etc.,  the  sole  object  being  to  abolish  motion  at  the 
diseased  joint  as  effectually  as  possible;  this  not  only  relieves  pain, 
but  has  direct  influence  in  checking  the  tuberculous  process.  By 
traction  is  understood  not  so  much  actual  extension  on  the  limb 
sufficient  to  pull  the  joint  surfaces  apart,  as  cessation  of  weight- 
bearing  and  relief  of  pressure:  it  acts  by  relieving  pain  and  securing 
rest,  but  also  prevents  deformity  which  is  prone  to  occur  wrhen  the 
weight  of  the  body  is  borne  on  the  softened  bone  ends.  Traction 
is  applied  chiefly  to  the  knee,  hip,  and  spine;  fixation  alone  usually 
is  sufficient  for  the  upper  extremity. 

Whenever  possible  in  the  spine  and  lower  extremity  the  advantages 
of  fixation  and  traction  should  be  combined.  This  is  best  accomplished 
by  bed-treatment,  so  long  as  acute  symptoms  persist,  regardless  of 
the  stage  of  the  disease.  Recumbency  at  once  removes  the  weight 
of  the  body  from  the  diseased  joints,  and  fixation  is  much  more  readily 
secured.  In  children,  the  use  of  a  Bradford  frame  (1890)  (Fig.  560) 
to  which  the  body  is  strapped,  provides  fixation  for  spine,  hip,  or 
knee,  in  the  most  efficient  manner.  This  frame  is  made  of  gas-pipe, 
and  is  covered  with  tightly  stretched  canvas;  it  should  be  a  little 
longer  than  the  patient  and  as  wide  as  from  one  armpit  to  the  other. 
The  child  is  fastened  to  it  by  a  broad  canvas  apron  covering  chest 
and  abdomen,  or  by  straps  crossing  the  shoulders.1  The  frame  thus 
becomes  a  part  of  the  child,  and  the  two  together  can  be  carried  about 
from  room  to  room,  or  from  ward  to  roof  garden  (Fig.  561),  thus 
preventing  the  painful  and  harmful  joint-movements  necessitated 
by  carrying  the  child  in  the  arms  or  transferring  it  to  a  stretcher 
and  back  again  to  the  bed.  Weight-extension  usually  is  a  desirable 
adjuvant  in  securing  joint  fixation,  and  is  the  most  effectual  method 

1  G.  G.  Davis  used  also  an  upper  frame,  well  padded  and  moulded  to  the  body, 
to  hold  the  child  against  the  lower  frame. 


TREATMENT  OF   TUBERCULOUS  ARTHRITIS 


525 


of  overcoming  pain  and  muscular  spasm,  to  which  latter  factor 
deformity  in  the  earliest  stages  is  due.  Weight-extension  always  should 
be  applied  in  the  axis  of  the  deformity  (Fig.  575),  and  as  spasm 


Fig.  560. — Bradford  frame.     See  text. 


lessens  the  direction  of  the  extension  can  be  gradually  changed  until 
the  normal  position  is  secured.  Great  care  must  be  exercised  during 
recumbent  treatment  to  keep  the  foot  at  a  right  angle  with  the  leg, 
preventing  the  development  of  talipes  equinus. 


Fig.  561. — On  the  roof  garden  of  the  Orthopaedic  Hospital.    Showing  Bradford 
frames  with  head  and  foot  extension. 


^Vhen  all  symptoms  of  arthritis  (limitation  of  motion  from  spasm, 
pain,  fever,  etc.)  have  been  absent  for  a  month  or  more,  recumbent 
treatment  may  be  discontinued.     This  stage  is  reached  after  two 


526  DISEASES  OF  JOINTS 

to  six  months  in  cases  coming  under  observation  in  the  early  stages 
of  the  disease.  If  local  treatment  (fixation  and  traction)  are  now 
recklessly  discontinued  in  the  erroneous  idea  that  the  joint  is  cured, 
and  if  the  patient  is  allowed  to  resume  joint  function,  it  will  be  only 
a  few  weeks  before  all  symptoms  of  arthritis  return,  and  possibly  in 
aggravated  form.  It  is  absolutely  imperative  to  guard  the  joint 
against  injury  and  strain  by  continuing  for  a  long  period  fixation  or 
traction,  or  both,  during  ambulatory  treatment.  By  the  use  of 
plaster  of  Paris  cases,  braces,  crutches,  etc.,  both  fixation  and  traction 
(in  modified  forms)  can  be  continued;  and  this  should  be  done  until, 
by  allowing  gradual  return  of  function  (first  limited  motion,  then 
weight-bearing),  the  surgeon  proves  that  the  joint  lesion  has  become 
so  thoroughly  encapsulated  as  not  to  be  liable  to  cause  recrudescence 
of  the  disease.  This  period  of  ambulatory  after-treatment  extends 
always  through  several  months,  usually  through  a  year  or  more,  and 
often  for  many  years.  Only  by  making  haste  slowly  can  permanent 
good  results  be  achieved.  If  there  is  any  reason  (there  are  few  good 
reasons)  why  recumbent  treatment  is  impossible  when  the  patient 
first  is  seen,  ambulatory  treatment  with  fixation  and  traction  may  be 
employed  from  the  start;  but  this  is  apt  to  promote  ankylosis,  and 
deformity  is  very  difficult  to  prevent.  Moreover,  in  many  cases  the 
symptoms  are  so  acute  that  rest  in  bed  is  an  absolute  necessity. 
Yet  I  believe  with  Coudray  (1911),  that  in  no  case  should  a  manifest 
tendency  toward  ankylosis  be  hindered;  the  joint  should  be  kept  in 
good  position,  but  attempts  to  preserve  motion  are  extremely  apt 
to  keep  the  disease  active.  The  surest  and  most  lasting  cures  are 
those  which  follow  ankylosis. 

Treatment  of  Cold  Abscesses. — If  the  joint  be  put  at  rest,  and  the 
patient  kept  in  the  open  air,  the  threatening  abscess  may  cease  to 
enlarge,  and  in  not  a  few  cases  gradually  will  disappear.  Hence 
these  conservative  measures  should  be  given  full  trial.  If  the  abscess 
continues  to  enlarge,  and  threatens  to  approach  the  skin,  with  the 
consequent  danger  of  infection  from  the  skin  cocci,  even  before 
spontaneous  rupture  makes  such  an  infection  sure,  I  think  it  is  best 
to  expose  the  abscess  wall  by  careful  dissection  through  overlying 
healthy  tissues,  to  incise  the  abscess,  evacuate  its  contents,  and  wipe 
the  abscess  cavity  gently  but  thoroughly  with  iodoform  gauze.  I 
cannot  see  that  anything  is  to  be  gained  by  curetting  the  walls  of  the 
abscess  cavity,  nor  by  attempts  to  "excise  the  sac,"  which  in  many 
cases  is  an  impossibility.  The  incision  to  reach  the  abscess  is  sutured 
in  layers,  without  drainage.  Children  should  be  anesthetized,  but  in 
adults  local  anesthesia  is  sufficient.  In  most  cases  (fifty-one  out  of 
sixty,  according  to  Starr,  1907),  the  incision  heals  without  breaking 
down  at  any  point,  and  in  only  a  very  few  cases  does  the  abscess  refill 
and  require  a  second  evacuation.  It  is  dangerous  to  leave  a  cold 
abscess  to  itself  until  the  overlying  skin  has  become  adherent  and 
reddened,  since  secondary  infection  from  skin  cocci  is  frequent,  and 
rapid  joint  disintegration,  hectic,  amyloid  disease,  etc.,  follow;  and 


TREATMENT  OF  TUBERCULOUS  ARTHRITIS  527 

it  is  still  more  dangerous  to  open  a  cold  abscess  without  perfectly 
aseptic  technique,  or  to  drain  it  by  tube  or  gauze  after  incision,  or 
to  allow  it  to  discharge  itself  spontaneously.  But  sometimes  the 
patient  is  not  seen  until  spontaneous  rupture  threatens,  and  secondary 
infection  already  is  present.  Under  such  circumstances  the  abscess 
should  be  evacuated  by  a  small  incision  where  it  is  pointing,  but 
should  not  be  drained;  the  puncture  should  be  occluded  with  aseptic 
gauze,  and  in  many  cases  little  or  no  subsequent  discharge  will  occur, 
the  "hot"  will  gradually  resume  its  character  of  "cold"  abscess, 
and  eventually  may  be  absorbed.  Thus  the  formation  of  sinuses  and 
prolonged  suppuration  may  be  prevented. 

Aspiration  of  a  cold  abscess  is  inferior  to  formal  incision,  because 
it  cannot  be  done  satisfactorily  until  the  pus  is  very  close  to  the 
surface  and  unless  it  is  very  fluid.  A  certain  number  of  cures,  however, 
will  follow  aspiration  and  injection  of  a  10  per  cent,  iodoform-glycerin 
emulsion. 

Treatment  of  Sinuses. — In  tuberculous  arthritis  sinuses  nearly 
invariably  are  an  indication  of  secondary  infection:  if  no  secondary 
infection  is  present  (a  fact  which  bacteriological  investigation  will 
demonstrate),  they  usually  will  heal  under  rest  and  constitutional 
treatment.  I  have  had  exceptionally  good  results  from  helio- 
therapy: the  sinuses  are  exposed  to  direct  sunlight,  beginning  with 
periods  of  five  minutes  twice  daily,  and  increasing  the  length  of  the 
exposures  as  rapidly  as  possible  without  producing  sunburn.  If 
the  sinuses  fail  to  heal,  and  if  discharge  of  pus  is  not  profuse,  they 
may  be  filled  with  bismuth  paste  after  the  method  of  Beck  (1905). 
This  is  heated  in  a  water  bath  until  fluid,  and  is  injected  into  the 
sinuses  by  a  syringe  which  after  being  boiled,  is  rinsed  in  alcohol  and 
allowed  to  dry  before  it  is  filled  with  the  liquid  paste.  The  sinuses 
are  filled  as  full  as  possible.  A  skiagraph,  made  after  distending  the 
sinuses  with  this  paste,  will  show  their  origin  and  ramifications  (Fig. 
562).  If  pus  should  be  dammed  up  behind  the  paste,  the  increased 
local  heat  will  cause  the  paste  to  melt,  and  it  will  be  extruded  from 
the  sinus  spontaneously.  The  mode  of  action  of  bismuth  paste  is 
not  certainly  known,  but  it  causes  marked  improvement,  the  dis- 
charge diminishing  and  the  sinuses  often  closing  in  a  comparatively 
short  time.  In  most  cases  the  strength  should  not  exceed  one  part  of 
bismuth  subnitrate  (arsenic  free)  to  ten  parts  of  sterile  amber  vaselin, 
Beck's  original  formula  (33  per  cent.)  having  been  responsible  for 
numerous  cases  of  bismuth  poisoning. 

If  profuse  suppuration  persists  in  spite  of  conservative  measures, 
it  is  probable  that  a  sequestrum  is  present,  and  this  may  be  removed 
by  curette  or  gouge.  Formal  operation  in  children  rarely  is  advisable. 
Injections  of  alcoholic  solutions  of  iodin  (2  to  10  per  cent.)  are  useful 
in  overcoming  secondary  infection. 

Operative  Treatment  in  Tuberculous  Arthritis. — It  might  be  thought 
that  early  excision  of  the  diseased  area  would  abort  the  disease,  but 
unfortunately  it  scarcely  ever  is  possible  to  locate  by  skiagraphy 


;.l's 


DISEASES  OF  JOINTS 


or  otherwise  an  extra-articular  focus;  nor  would  what  might  be  con- 
sidered total  extirpation  of  the  focus  amount  to  much  more  than 
removal  of  the  center  of  an  area  infected  far  beyond  what  is  indicated 
by  gross  appearances.    When  once  the  joint  itself  is  involved,  only  a 


Fig.  562. — Skiagraph  of  tuberculous  arthritis  of  left  hip,  with  sinus  discharging  on 
outer  surface  of  thigh;  sinus  has  been  distended  with  Heck's  bismuth  paste.  Boy,  aged 
ten  years;  coxalgia  for  six  years.  Abscess  punctured  three  months  before  skiagraph  was 
made,  because  it  was  pointing  and  because  there  was  secondary  infection  from  skin 
cocci.     Sinus  soon  closed  and  remained  healed  five  years  later.     Orthopffidic  Hospital. 


formal  excision  could  remove  all  the  disease,  and  in  children  such  an 
operation,  which  implies  removal  of  the  epiphyses,  is  productive  of 
such  marked  deformity  and  disability  as  to  be  generally  condemned 
by  intelligent  surgeons.  Moreover,  in  children,  the  results  of  con- 
servative treatment  thoroughly  carried  out,  as  outlined  above,  are 


TREATMENT  OF  TUBERCULOUS  ARTHRITIS  529 

so  satisfactory,  that  operation  presents  no  advantages  in  the  early 
stages  of  the  disease.  In  advanced  secondary  infection  in  children, 
however,  excision  may  be  imperative  as  a  means  of  joint  disinfection; 
and  in  adults,  the  results  of  conservative  treatment  have  proved  so 
disheartening,  chiefly  through  their  inability  to  endure  confinement  to 
bed,  and  their  tendency  to  develop  phthisis,  that  joint  excision  or  even 
amputation  is  the  accepted  form  of  treatment.  Ely  (1911)  claims  that 
an  excision  which  will  produce  ankylosis  and  thus  permanently  abolish 
joint  function  is  all  that  is  necessary  to  effect  a  cure;  he  asserts  that  it 
matters  not  how  little  bone  is  removed,  nor  how  much  tuberculous 
material  is  left,  so  long  as  ankylosis  is  obtained,  as  this  in  itself  will 
cause  disappearance  of  synovia,  which  is  the  joint  tissue  on  which  in 
adults  tubercle  bacilli  almost  solely  subsist.  But  hitherto  it  has  been 
the  habit  of  surgeons  to  remove  as  much  diseased  tissue  as  possible.  In 
children,  excisions,  if  done,  should  be  limited  to  the  epiphyses  of  the 
bones,  the  epiphyseal  cartilages  being  rigorously  respected,  and  any 
focus  in  the  metaphysis  should  be  evacuated  by  the  curette  through 
a  perforation  of  the  epiphyseal  cartilage,  and  not  by  sawing  off  the 
bone  end  until  all  diseased  tissue  disappears.  Arthrectomy  or  erasion 
of  joints,  adapted  especially  to  the  knee,  was  introduced  by  Wright, 
of  Manchester  (1881),  and  in  this  country  by  J.  Ashhurst,  Jr.  (1889), 
as  a  substitute  for  excision  in  children;  it  aims  to  remove  all  the  diseased 
soft  tissues  (synovia,  ligaments,  cartilages)  without  invading  the 
bones;  and  may  be  employed  for  the  purpose  of  effecting  ankylosis 
when  conservative  measures  fail  to  secure  subsidence  of  symptoms. 
Treatment  of  Ankylosis  from  Tuberculous  Arthritis. — As  has  already 
been  indicated,  ankylosis  following  tuberculous  arthritis  often  implies 
merely  a  latency  of  the  disease,  though  no  doubt  definitive  cure 
sometimes  occurs.  But  owing  to  the  frequency  with  which  slight 
trauma,  even  many  years  after  ankylosis  has  occurred,  may  rouse 
the  dormant  lesion  into  activity,  the  surgeon  should  be  extremely 
cautious  in  efforts  to  restore  joint  motion.  If  ankylosis  has  occurred 
in  good  position,  especially  in  the  joints  of  the  lower  extremity,  no 
treatment  should  be  adopted,  as  a  rule.  For  deformity  at  the  hip, 
subtrochanteric  osteotomy  (p.  510)  is  the  best  treatment,  as  it  divides 
the  bone  where  healthy  (just  below  the  lesser  trochanter),  and  there 
is  very  little  risk  of  rousing  the  old  disease,  especially  if  the  bone 
section  is  made  with  a  saw  instead  of  by  osteotome  and  mallet.  A 
puncture  is  made  about  4  cm.  below  the  great  trochanter,  on 
the  outer  side  of  the  femur,  with  Adams's  knife;  this  is  passed 
directly  to  the  bone,  and  is  then  carried  across  its  anterior  surface, 
and  along  this  knife  as  a  guide,  Adams's  saw  is  passed;  the  knife 
is  then  withdrawn,  and  the  femur  is  divided  by  very  gentle  sawing. 
The  limb  is  then  brought  into  a  position  of  abduction  and  nearly 
full  extension  (Figs.  563  and  504).  Tenotomy  of  the  adductors  may 
be  necessary  to  secure  abduction.  The  limb  is  then  fixed  in  this 
position  in  plaster  of  Paris,  and  is  treated  as  a  recent  fracture.  At 
the  knee,  formal  excision  (p.  510)  usually  will  secure  a  useful  and 
34 


530 


DISEASES  OF  JOINTS 


straight  limb,  though  still  ankylosed;  attempts  at  arthroplasty  in 
tuberculous  knees  are  to  be  condemned.  An  ankylosed  elbow  causes 
great  disability  even  if  ankylosis  has  occurred  at  the  best  possible 
angle,  and  excision  may  properly  be  done  with  the  aim  of  restoring 
motion.    The  same  is  true  of  the  shoulder. 


Fig.  563. — Ankylosis  of  hip  from  old 
coxalgia,  age  thirteen  years.  Ortho- 
paedic Hospital. 


Fig.  564. — Same  patient  as  Fig.  563; 
one  year  after  subtrochanteric  osteotomy 
of  femur.    Orthopaedic  Hospital. 


Tuberculosis  of  the  Hip. — Pathology  — The  primary  lesion  is  in 
the  neck  or  head  of  the  femur  in  most  cases,  but  occasionally  the 
acetabulum  or  synovia  is  first  involved.  Acetabular  and  synovial 
disease  are  intra-articular  from  the  beginning;  and  a  femoral  lesion 
very  soon  penetrates  the  joint,  the  epiphysis  of  the  head  being  intra- 
articular. Thus  in  all  cases  invasion  of  synovia  occurs  early,  and  in 
many  the  acetabulum  remains  healthy  for  only  a  short  period.  There 
is  marked  rarefaction  of  the  bone,  nearly  all  calcareous  matter  dis- 
appearing; the  skiagraphic  picture  (Fig.  565)  is  not  unlike  that  of 
round-celled  sarcoma  of  bone  in  the  total  obliteration  of  all  land- 
marks. If  weight-bearing  is  continued,  the  acetabulum  may  be 
enlarged    upward    and   backward    ("wandering   acetabulum"),    and 


Fig.  565.  —  Skiagraph  of  tuberculosis  of  left  hip-joint.  Boy,  aged  five  years, 
duration  five  months.  Note  abduction  and  flexion  of  thigh;  absorption  of  head  of  femur 
and  involvement  of  acetabulum.     Orthopaedic  Hospital. 


Fig.  566.— Skiagraph  of  ankylosis  of  right  hip  following  tuberculosis.  Girl,  aged 
thirteen  years;  coxalgia  at  nine  years;  no  symptoms  for  two  years;  healed  sinus  present 
in  groin.    Note  obliquely  contracted  pelvis.    Orthopaedic  Hospital. 


532 


DISEASES  OF  JOINTS 


pathological  luxation  may  occur;  if  this  is  an  early  symptom  in  cases 
in  which  weight-bearing  lias  not  been  allowed,  it  generally  is  due  to 
rupture  of  the  capsule  from  intra-articular  effusion.  The  head  of  the 
femur  may  become  very  much  altered  in  shape,  or  entirely  absorbed; 
and  when  secondary  pyogenic  infection  is  present,  pathological  fracture 
of  the  neck  is  not  very  rare  (Fig.  558).  The  best  result  in  such  cases 
is  firm  ankylosis  (Fig.  566). 

Symptoms  and  Clinical  Course. — When  early  symptoms  of  tuber- 
culous joint  disease  (p.  521)  point  to  the  hip,  the  patient  should  be 
attentively  examined  after  removal  of  all  clothing.  Nearly  90  per 
cent,  of  cases  are  in  children  under  ten  years  of  age.  First  the 
gait  (bare-footed)  should  be  studied:  usually  a  slight  limp  will  be 
noted;  and  in  the  early  stages  the  thigh  is  held  in  slight  flexion 
and  abduction,  causing  flattening  of  the  buttock  and  obliteration  of 
the  gluteal  fold  on  the  affected  side  (Fig.  5(57).  The  patient  is  then 
laid  flat  on  his  back  on  a  firm  table:  measurements  from  the  navel  to 
the  malleoli  may  show  apparent  lengthening  of  the  affected  extremity; 
this  is  due  to  its  abduction,  but  if  the  healthy  limb  is  placed  in  a 
similar  degree  of  abduction  the  discrepancy  will  disappear.  Unless 
there  is  marked  bone  deformation  or  dislocation  there  can  be  no  actual 
change   in  the  length  of  the  limbs.     Examination  usually  is  best 

begun  by  testing  the  motions  of  the 
normal  limb,  making  all  the  tests 
with  extreme  gentleness,  and  aiming 
to  gain  the  child's  confidence.  Usually 
the  affected  thigh  is  kept  slightly 
flexed  (Fig.  508),  and  when  an  at- 
tempt is  made  to  bring  it  out 
straight,  the  lumbar  spine  rises  from 
the  table  (Fig.  569)  because  the  hip 
is  held  rigidly  in  flexion,  and  motion 
is  transferred  to  the  spine.  First 
rotate  the  lower  extremity  gently  to 
and  fro  in  its  own  axis,  comparing 
the  motion  in  the  two  limbs;  there 
will  be  little  or  at  least  limited  rota- 
tion on  the  diseased  side,  and  it  will 
be  painful.  Then  try  abduction  of 
the  thigh,  still  keeping  the  limb  as 
fully  extended  as  possible;  on  the 
diseased  side  abduction  usually  is 
markedly  limited  by  the  muscular 
spasm.  The  range  of  flexion  is  next 
investigated,  first,  by  bringing  the 
sound  thigh  up  against  the  abdo- 
men, and  then  comparing  this  with 
flexion  in  the  diseased  joint;  this  usually  is  somewhat  limited, 
but  not  so  markedlv  as  rotation  and  abduction.     Next,  abduction 


Fig.  567. — Tuberculosis  of  the  left 
hip.  First  stage:  flexion  and  abduc- 
tion; flattening  of  buttock  and  oblit- 
eration of  the  gluteal  fold.  Age  five 
years;  duration  two  months.  Ortho- 
paedic Hospital. 


TUBERCULOSIS  OF   THE  HIP 


533 


Fig.  568. — Tuberculosis  of  right  hip  for  nine  months.  Age  three  years.  The  hip  is 
held  in  a  flexed  position  by  muscular  spasm,  and  the  lumbar  spine  lies  flat  on  the  table. 
(See  Fig.  569.)     Orthopaedic  Hospital. 


Fig.  569. — Tuberculosis  of  right  hip  (see  Fig.  568),  showing  arching  of  lumbar  spine 
when  attempt  is  made  to  bring  the  knee  down  on  the  table.  Motion  occurs  in  the 
lumbar  spine,  not  in  the  hip-joint.    Orthopaedic  Hospital. 


Fig.  570. — Deformity,  following  tuber- 
culosis of  hip:  adduction  and  shortening 
(six  inches).  Age  sixteen  years;  onset 
of  disease  at  three  years;  healed  sinuses. 
No  symptoms  for  the  last  eight  years. 
Orthopaedic  Hospital. 


Fig.  571. — Extreme  exterior  rotation 
following  tuberculosis  of  hip.  Age  twelve 
years.  Duration  four  years;  sinuses  still 
open.  (Dr.  Alexander's  case.)  Episcopal 
Hospital. 


534 


DISEASES  OF  JOINTS 


with  the  thigh  flexed  to  a  right  angle  may  be  tested;  this  is  always 
much  decreased  on  the  diseased  side.  Then  the  child  is  turned  over 
on  its  stomach,  and  the  range  of  hyperextension  is  tested  iii  each 
hip  by  raising  the  knee  from  the  table;  this  movement  always  is 
limited  on  the  diseased  side,  and  where  marked  flexion  deformity 
is  present,  it  is  manifestly  unnecessary  to  test  hyperextension.  If 
any  of  these  motions  are  persistently,  even  if  only  very  slightly 
limited,  and  if  there  is  a  history  typical  of  the  onset  of  tuberculous 
arthritis,  the  diagnosis  may  be  considered  established;  and  if  an  exami- 
nation such  as  above  indicated  were  systematically  made  by  the 
physician  first  called  to  attend  the  patient,  and  if  proper  treatment 
were  instituted,  valuable  time  would  be  saved.  Only  too  frequently 
the  family  physician  makes  no  physical  examination  at  all,  or  only 
a  partial  one,  hampered  by  the  patient's  clothing;  and  treatment 

for  a  sprain  or  for  rheumatism  is  pre- 
scribed, when  a  very  little  more  trouble 
would  have  enabled  a  correct  diagnosis 
to  be  made.  In  the  rare  cases  where 
the  signs  are  so  slight  as  to  render 
a  positive  diagnosis  hazardous,  the 
surgeon  will  consult  his  own  and  the 
patient's  interests  much  better  by 
enjoining  recumbent  treatment  for  a 
week  or  two,  than  by  making  light 
of  the  malady. 

At  a  later  stage  of  the  disease,  the 
early  deformity  of  abduction  is  replaced 
by  adduction,  possibly  owing  to  atrophy 
of  the  iliopsoas  which  lies  closest  to 
the  joint,  and  the  unopposed  action 
of  the  adductors.  In  efforts  to  walk 
the  patient  has  to  bring  the  lower 
extremities  parallel,  and  as  the  dis- 
eased limb  is  fixed  in  adduction,  the 
healthy  limb  must  be  abducted  to 
correspond;  this  causes  a  descent  of 
the  pelvis  on  the  unaffected  side,  and 
apparent  shortening  of  the  diseased 
extremity.  But  if  the  healthy  limb 
is  placed  in  a  similar  attitude  of 
adduction,  the  measurements  will  be 
found  the  same,  unless  bone  destruction  or  dislocation  is  present. 
The  deformity  of  flexion  and  adduction,  in  this  which  is  called  the 
second  stage  of  '"coxalgia,"  may  be  due  in  part  to  intra-articular 
changes,  but  most  of  it  is  due  to  muscular  contractures  which  may 
be  overcome  by  joint  fixation  and  traction. 

At  a  still  later  stage  of  the  disease  the  patient  may  come  under 
observation  with  cold  abscess  or  sinuses,  and  with  ankylosis  in  almost 


Fig.  572. — Cold  abscess  of  left 
thigh,  from  tuberculosis  of  hip. 
Sequestrum  discharged  later.  Age 
four  years;  duration  three  years. 
Orthopaedic  Hospital. 


TUBERCULOSIS  OF  THE  HIP 


535 


any  position  (Figs.  570  and  571),  or  with  pathological  luxation.  Cold 
abscesses  and  sinuses  usually  are  in  direct  communication  with  the 
joint  cavity,  but  occasionally  are  due  to  extra-articular  perforation 
of  the  bone.  The  abscess  may  point  at  any  part  of  the  thigh,  but 
the  most  frequent  site  is  on  the  outer  side  (Fig.  572) ;  or  a  gluteal 
abscess  (Fig.  573)  may  occur,  usually  from  perforation  of  the  poste- 


Fig.  573. — Gluteal  abscess  in  coxalgia.     (Dr.  Hodge's  case.)     Children's  Hospital. 

rior  capsule.  Abscesses  or  sinuses  in  the  adductor  region  (Fig.  574) 
usually  are  an  evidence  that  the  acetabulum  is  involved,  as,  accord- 
ing to  Vincent  (1895)  is  the  occurrence  of  adduction  as  the  primary 
deformity. 

Diagnosis. — Not  every  case  of  arthritis  of  the  hip  is  tuberculous, 
even  in  children,  and  where  doubt  exists  as  to  the  etiological  factor, 
other  aids  may  be  called  in  to  assist  the  clinical  diagnosis,  such  as  the 


Fig.  574.- 


-Adductor  abscess  in  coxalgia.        Age  six  years.       Coxalgia  for  one  year. 
Abscess  for  four  weeks.     Orthopaedic  Hospital. 


tuberculin  tests,  estimation  of  the  leukocytes,  and  skiagraphy.  Nor 
should  the  surgeon  forget  that  other  affections  besides  arthritis  may 
cause  rigidity,  flexion,  adduction,  etc.  Among  such  may  be  mentioned 
inguinal  or  femoral  adenitis,  osteochondritis  (p.  588),  psoas  abscess 
(p.  661),  and  even  appendicitis.  Attention  to  the  clinical  history  and 
physical  signs  will  exclude  such  affections  as  fracture  of  the  cervix 


:>:',<; 


DISEASES  OF  JOINTS 


femoris,  congenital  or  traumatic  dislocation  of  the  hip,  coxa  vara, 
and  deformity  from  infantile  arthritis. 


Fig.  575. — Bed  extension  for  coxalgia  with  flexion  deformity.     Note  the  high  cradle 
to  keep  the  bed-clothes  off  the  foot.     Episcopal  Hospital. 


Fig.  576. — Thomas  hip  brace. 
Episcopal  Hospital. 


Fig.  577. — Thomas  hip  brace 
rear  view. 


Treatment. — Recumbency  should  be  insisted  on  in  all  early  cases, 
with  weight  extension  of  two  or  three  pounds  applied  in  the  axis  of 


TUBERCULOSIS  OF  THE  HIP  537 

the  deformity  (Fig.  575).  Sufficient  fixation  usually  is  secured  by 
strapping  the  body  to  a  Bradford  frame.  If  this  cannot  be  procured, 
a  binder's-board  splint  or  light  plaster  case  may  be  applied  to  the 
hip  and  pelvis,  weight-extension  being  used  in  addition.  In  most 
cases,  after  a  week  or  two,  muscular  spasm  disappears  and  full  ex- 
tension may  be  secured.  The  temperature  should  be  recorded  twice 
daily,  in  this  as  in  all  acute  tuberculous  conditions;  it  forms  a  valu- 
able guide  as  to  the  progress  of  the  local  lesion.  After  one  or  two 
months  of  recumbency  examination  may  disclose  an  apparently  nor- 
mal joint,  and  the  temperature  curve  may  be  quite  satisfactory; 
but  this  merely  indicates  that  the  disease  is  latent,  not  that  it  is 
cured. 

When  symptoms  have  been  absent  for  a  month  or  more,  ambula- 
tory treatment  may  be  cautiously  tried.  In  this,  joint  fixation  may 
be  gradually  relaxed,  but  weight-bearing  should  be  prevented  for  a 
long  time  to  come.  Various  braces  are  in  use  for  this  stage  of  treat- 
ment: with  all,  a  high  shoe  is  worn  on  the  healthy  side,  and  crutches 
are  used,  allowing  the  diseased  limb  to  swing  free  of  the  ground.  The 
brace  of  H.  O.  Thomas  (1875)  (Figs.  576  and  577),  provides  fixation 
at  the  hip,  and  traction  is  secured  by  the  weight  of  the  limb ;  but  it 
is  impossible  for  the  patient  to  sit  down  with  the  brace  on,  and 
the  limb  may  rotate  within  the  brace,  giving  rise  to  unsuspected 
deformity.  About  1855  H.  G.  Davis  introduced  the  method  of  traction 
in  an  ambulatory  splint;  a  modification  of  this,  introduced  in  1873  by 
C.  F.  Taylor  (Fig.  578),  consists  of  a  pelvic  band,  passing  around  the 
pelvis  between  the  anterior  superior  iliac  spines  and  the  level  of  the 
great  trochanters,  to  which  is  attached  a  long  outside  iron  extending 
below  the  foot  beneath  which  it  forms  a  stirrup;  to  the  stirrup  traction 
straps  are  fastened  from  the  foot,  counter-extension  being  provided 
by  a  perineal  strap.  Movements  of  flexion  and  extension  are  per- 
mitted at  the  hip,  as  the  outside  iron  is  jointed  below  the  pelvic  band; 
this  allows  a  sitting  posture  to  be  assumed.  A  more  efficient  brace 
is  that  of  G.  G.  Davis  (Fig.  579),  in  which  besides  a  perineal  strap  for 
counter-extension,  as  in  the  Taylor  brace,  an  inside  iron  is  added 
which  supports  a  well-padded  bar  passing  from  one  side  iron  to  the 
other  beneath  the  tuber  ischii;  on  this  bar  the  patient  sits,  absolutely 
preventing  weight-bearing  on  the  diseased  joint,  while  the  foot  exten- 
sion keeps  the  lower  extremity  taut,  aiding  the  weight  of  the  limb 
in  securing  traction.  If  braces  cannot  be  secured,  a  spica  bandage 
of  plaster  of  Paris  may  be  applied  to  the  thigh  and  pelvis,  preferably 
fixing  the  knee  and  ankle  also;  and  with  a  high  shoe  on  the  sound  side, 
and  crutches,  the  patient  may  do  well,  though  a  well-fitting  brace  is 
much  more  cleanly  and  comfortable.  Usually  it  is  well  for  the  brace  to 
be  worn  night  and  day  at  first,  until  it  is  certain  that  no  recurrence  of 
symptoms  is  to  be  feared,  when  it  may  be  left  off  at  night.  While 
a  patient  is  wearing  a  brace,  he  should  be  seen  by  the  surgeon  every 
two  or  three  weeks;  and  the  surgeon  should  himself  see,  personally, 
that  the  brace  fits  comfortably  and  is  efficient.     If  he  is  unwilling 


:>:n 


DISEASES  OF  JOINTS 


or  unable  to  undertake  the  responsibilities  of  mechanical  treatment, 
he  should  retire  from  the  case. 

If  it  is  found  that  under  ambulatory  treatment  symptoms  of 
coxitis  return,  recumbent  treatment  should  be  resumed,  and  carried 
out  as  already  indicated.  When,  however,  ambulatory  treatment 
succeeds,  joint  fixation  may  be  gradually  dispensed  with.  If  eight 
months  or  a  year  are  passed  without  any  symptoms  whatever  of 
joint  trouble,  it  probably  will  be  safe  to  discard  the  brace,  but  a 
high  shoe  on  the  sound  side  and  the  use  of  crutches  should  be  insisted 
on  for  a  much  longer  period.  Then  the  high  shoe  may  be  abandoned, 
and  crutches  alone  used,  until  by  very  gradual  stages  weight-bearing 
is  proved  safe. 


1 

Fig.  578. 


-Taylor  hip  brace.     Episcopal 
Hospital. 


Fig.  579. — G.  G.  Davis's  brace  for 
coxalgia.    Orthopedic  Hospital. 


I  am  well  aware  that  some  orthopedic  surgeons  at  present  are 
opposed  to  such  conservative  measures,  and  prefer  to  follow  the 
example  of  Lorenz  (1906),  in  treating  all  early  cases  of  coxalgia  by 
weight-bearing,  fixing  the  joint  in  the  attitude  of  deformity  by  a 
gypsum  splint,  and  abolishing  recumbency  and  traction  entirely 
from  their  plan  of  treatment.  But  the  plan  here  recommended  seems 
to  me  the  most  rational  when  the  pathology  of  the  lesions  is  con- 


TUBERCULOSIS  OF  THE  HIP 


539 


sidered,  and  is  still  employed  by  the  majority  of  judicious  surgeons 
in  this  country,  Great  Britain,  and  France;  and  I  am  convinced  that 
if  rigorously  employed  from  the  earliest  stage,  it  will  cure  a  much 
larger  proportion  of  patients  without  ankylosis  than  will  the  method 
of  Lorenz,  though  the  course  of  treatment  may  be  longer. 


Fig.  580. — Result  of  excision  of  hip  for 
tuberculosis,  in  a  boy  of  fourteen  years, 
one  year  after  operation.  Still  uses 
crutches.  (Dr.  H.  C.  Deaver's  case.)  (See 
Fig.  581.)      Episcopal  Hospital. 


Fig.  581.— Excision  of  left  hip  for 
coxalgia.  (See  Fig.  580).  Left  hip  in 
slight  adduction;  apparent  shortening 
three  inches,  actual  shortening  one  and 
a  half  inches;  wound  dry  but  scabby. 


The  treatment  of  cold  abscess  and  sinuses,  with  secondary  infection, 
has  been  so  fully  discussed  at  p.  520,  that  little  need  be  said  here.  In 
almost  all  cases  recumbent  treatment,  and  heliotherapy,  alone  or  with 
bismuth  or  iodin  injections,  will  cause  sinuses  to  close  eventually.  Very 
rarely  it  may  be  necessary  to  remove  a  sequestrum  or  some  carious 
bone  by  the  curette;  then  the  cavity  should  be  filled  with  iodoform 
bone-wax  (p.  478).  Almost  never  is  formal  excision  necessary  or 
desirable  in  children,  and  then  only  to  avert  death  from  sepsis,  and 
as  a  less  severe  remedy  than  amputation.  Excision  of  the  hip  for 
tuberculosis  should   be   regarded   merely  as  a  method  of  joint  dis- 


540 


DISEASES  OF  JOINTS 


infection  (Coudray,  L911),  and  should  be  as  conservative  in  extent 
as  is  possible  with  such  end  in  view.  An  anterior  incision  is  best, 
as  originally  advocated  by  Hueter  (1878),  and  later  adopted  by 
R.  W.  Parker;  this  incision  is  made  on  the  outer  side  of  the  sartorius, 
displacing  the  rectus  and  ilio-psoas  to  the  inner  side  (Barker,  1888); 
as  much  synovia  should  be  removed  as  possible.  In  very  septic 
cases  the  posterior  longitudinal  incision  is  preferable.  This  was  used 
by  C.  White,  of  .Manchester  (  L769),  and  was  known  during  the  nine- 
teenth century  by  Langen- 
beck's  name.  After  detaching 
the  muscles  from  the  great  tro- 
chanter the  femur  is  divided 
below  this  process,  the  entire 
upper  end  being  removed;  the 
acetabulum  also  is  gouged 
away  if  necrotic.  Though  the 
immediate  mortality  of  the 
operation  is  only  about  5  per 
cent.,  yet,  when  employed  for 
the  cases  here  described  as 
suitable  for  such  treatment, 
the  ultimate  death  rate  is 
from  20  to  25  per  cent.  If 
employed  in  less  severe  cases 
in  which  it  is  not  necessary, 
the  death  rate  will,  of  course, 
be  less.  Amputation  occa- 
sionally may  save  a  life  after 
excision  and  re-excision  have 
failed.  After  the  operation 
recumbent  treatment  with 
fixation  and  traction  is  con- 
tinued until  latency  of  symp- 
toms indicates  the  propriety 
of  passing  to  ambulatory 
treatment.  Ankylosis  should 
be  encouraged.  Ely  (1911) 
thinks  the  benefit  of  excision 
in  hip  disease  is  due  to  the 
luxation  of  the  femur  which 
often  results,  thus  permanently  abolishing  the  joint  as  such,  as  effect- 
ually as  would  ankylosis  (p.  524).  In  long  quiescent  cases  with  anky- 
losis, deformity  may  be  corrected  by  osteotomy  (p.  529);  without 
ankylosis,  disability  may  be  relieved  by  an  operation  replacing  the 
upper  end  of  the  femur  in  the  acetabulum. 

In  adults,  in  whom    tuberculosis  of  the   hip  is  rare,    excision    is 
more  often  required,  but,  fortunately,  the  resulting  disability  is  less. 


Fig.  582. — Skiagraph  of  tuberculous  arthritis 
of  knee;  age  thirty-seven  years;  duration  seven 
years.  Same  patient  as  in  Fig.  583.  Episcopal 
Hospital. 


TUBERCULOSIS  OF   THE  KNEE 


541 


Tuberculosis  of  the  Knee. — This  is  the  most  frequent  form  of 
tuberculous  joint  disease  in  adults,  in  whom  the  primary  lesion  often 
is  synovial;  but  the  knee  is  often  attacked  in  children  also,  and  in 
them  usually  the  femur,  tibia,  or  patella  is  first  involved.  In  the 
knee,  as  in  the  elbow,  local  signs  of  arthritis  are  much  more  marked 
than  in  the  hip,  consisting  in  heat,  dusky  redness,  typical  fusiform 
swelling,  and  occasionally 
in  intra-articular  effusion. 
Usually,  however,  enlarge- 
ment of  the  joint  is  due  to 
fungus  granulation  tissue, 
and  though  it  may  seem  as 
if  fluctuation  was  present, 
aspiration  will  fail  to  de- 
monstrate fluid.  The  pa- 
tella does  not  float,  but 
early  becomes  fixed  more 
or  less  firmly  to  the  con- 
dyles of  the  femur  (Fig. 
582).  The  knee  is  flexed, 
and  contractures  of  the 
hamstrings  develop.  In  ad- 
vanced cases  posterior  sub- 
luxation of  the  tibia  occurs, 
usually  accompanied  also 
by  rotation  outward.  Start- 
ing pains  are  very  annoy- 
ing, and  the  patient  lies 
curled  up  on  the  diseased 
side,  his  whole  attention 
apparently  concentrated  in 
protecting  the  painful  joint 
from  injury  or  motion. 
Cold  abscess  is  rarer  than 
in  hip  disease,  and  sinuses 
more  frequently  are  of 
extra-articular  origin. 

Treatment.  —  The  treat- 
ment consists  in  local  rest, 
secured  in  acute  cases  by 
recumbency  with  splinting 

and  weight-extension.  In  less  severe  cases  the  fixation  by  plaster  of 
Paris  without  traction  may  suffice,  and  if  the  gypsum  is  renewed 
every  four  or  five  weeks  gradual  decrease  of  the  deformity  may  be 
secured.  Weight-bearing  usually  should  be  allowed  before  motion  at 
the  knee,  but  for  some  months  after  ambulatory  treatment  is  com- 
menced it  is  safer  to  employ  a  traction  brace,  much  the  same  as  in  hip 
disease,  with  a  high  shoe  on  the  healthy  foot,  and  crutches.     If  con- 


Fig.  583. — Skiagraph  of  tuberculous  arthritis  of 
knee,  showing  destruction  of  external  condyle  of 
femur,  external  tuberosity  of  tibia  and  perforation 
of  cartilage  of  tibia.  Age  thirty-seven  years; 
duration  seven  years.  Probably  synovial  in 
origin.     Treated  by  excision.    Episcopal  Hospital. 


542 


DISEASES  OF  JOINTS 


servative  treatment  is  persisted  in  for  a  year,  and  the  disease  fails  to 
become  latent,  the  question  of  operative  treatment  may  arise:  in  cliil- 
dren  below  the  age  of  puberty  all  that  should  be  attempted  is  erasion 
of  the  joint  (arthreetomy,  p.  529);  and  though  by  resort  to  this 
operation  the  disease  may  not  be  permanently  cured,  and  though,  as 
is  frequent,  flexion  deformity  develops  after  operation,  it  may  be 
possible  by  its  aid  to  tide  the  patient  over  the  years  of  childhood 
until  formal  excision  can  be  safely  done.  In  adults  the  results  of 
conservative  treatment  are  very  disappointing  (Fig.  583) ;  if,  after 
judicious  trial  of  this  for  some  months,  no  improvement  occurs, 
or  if  the  disease  constantly  lights  up  afresh  when  ambulatory 
treatment  is  adopted,  excision  of  the  knee  should  be  done;  and  in 
practically  all  cases  in  adults  with  sinuses  or  secondary  infection, 
early  excision  will  give  the  best  results   (Fig.  584).      The  operation 


Fig.  584. — Specimen  from  excision  of  left 
knee  for  tuberculosis.  (See  Figs.  582  and 
583.)  Episcopal  Hospital. 


Fig.  585. — Tuberculosis    of  left 
ankle-joint.     Episcopal  Hospital. 


has  been  described  at  p.  510.  Ankylosis  should  be  firm  in  eight 
to  ten  weeks.  Even  if  excision  fails  to  cure  the  disease  at  once, 
which  rarely  is  the  case,  the  surgeon  must  not  conclude  that  immediate 
amputation  is  necessary;  by  persistence  in  conservative  measures,  firm 
ankylosis  and  healing  of  sinuses  may  yet  occur;  or  a  re-excision  may 
be  more  successful.  Amputation  should  be  regarded  as  the  last 
resort,  chiefly  adapted  to  the  very  old.  By  excision  the  limb  will  be 
shortened  from  1.5  to  5  cm.  During  convalescence  from  operation 
the  tendency  to  development  of  genu  varum  must  be  guarded  against, 
as  well  as  the  tendency  of  the  femur  to  ride  forward  on  the  tibia.  The 
patient  should  wear  an  orthopedic  apparatus  to  fix  the  knee  for  a  year. 
The  immediate  mortality  of  the  operation  is  about  5  to  10  per  cent. 

Tuberculosis  of  the  Ankle  and  Tarsus.— The  diagnosis  sometimes 
is  difficult  in  children  or  adolescents,  in  whom  painful  flat-foot  (p.  591) 
may  be  the  primary  symptom.    The  astragalus  and  calcaneum  are 


TUBERCULOSIS  OF   THE  ELBOW 


543 


the  bones  most  often  affected,  but  owing  to  the  proximity  of  so 
much  synovial  membrane  (Fig.  179),  early  joint  invasion  occurs  (Fig. 
585),  and  fistulization  with  secondary  infection  is  very  common. 

Treatment. — Treatment,  even  when  the  diagnosis  is  only  tentative, 
should  be  by  rest  and  cessation  of  weight-bearing,  secured  by  a  gypsum 
case  and  use  of  crutches.  This  usually  is  sufficient  in  children,  in 
whom  sinuses  soon  close,  and  erasion  rarely  is  required.  If  motion 
is  prevented  by  a  suitable  brace,  weight-bearing  may  be  resumed  a 
few  months  after  cessation  of  active  symptoms.  In  adults,  on  the 
other  hand,  time  should  not  be  lost  in  conservative  treatment  unless 
improvement  is  progressive;  if  the  disease  seems  stationary,  and 
especially  if  the  foot  grows  worse,  erasion  or  excision  should  be  resorted 
to  without  delay.     The  entire  astragalus  should  be  removed,  and  as 


Fig.  586. — Tuberculosis  of  elbow  in  a 
child  of  four  years,  showing  typical 
fusiform  swelling;  also  tuberculous  spon- 
dylitis, and  tuberculous  osteomyelitis 
of  left  forearm  and  hand  with  sinuses. 
This  condition  is  euphoniously  described 
as  the  "moist rot."  Children's  Hospital. 


Fig.  587. — Tuberculosis  of  elbow. 
Age  seven  years;  duration  four  years; 
sinuses  for  four  months.  Also  tuber- 
culous cervical  adenitis.  (See  Fig.  588.) 
Orthopaedic  Hospital. 


much  of  the  tuberculous  soft  parts  as  possible.  Usually  the  surgeon 
finds  that  he  has  delayed  too  long,  and  that  while  this  con- 
servative operation  may  improve  matters  for  a  while,  amputation 
eventually  will  be  necessary. 

Tuberculosis  of  the  Elbow  is  much  more  frequent  in  children  than 
in  adults.  The  primary  lesion  is  more  often  in  the  ulna  or  humerus 
than  in  the  radius.  Joint  invasion  is  rapid,  and  typical  fusiform  en- 
largement results  (Fig.  586).  Fistulization  is  difficult  to  prevent 
(Fig.  587),  and  cure  seldom  occurs  except  by  ankylosis,  and  it  is 
better,  especially  in  children,  to  encourage  ankylosis  and  closure  of 
sinuses  than  to  resort  to  precocious  excision  (Fig.  588).  No  effort 
should  be  made  to  restore  motion  until  all  symptoms  have  been  absent 
for  many  months.     Then  excision  may  be  done. 


544 


DISEASES  OF  JOINTS 


Tuberculosis  of  the  Wrist. — This  is  rare  in  children;  immobilization 
promptly  employed  and  long  continued  usually  produces  a  cure  with 

only  moderate  limitation  of 
motion.  In  adults  sinuses 
are  prone  to  form,  and 
amputation  is  the  usual 
termination,  though  erasion 
should  he  tried  first.  Formal 
excision  of  the  wrist  is  very 
rarely  advisable  (p.  513); 
firm  fibrous  ankylosis  is 
sought,  and  the  hand  seldom 
is  very  useful. 

Tuberculosis  of  the  Sacro- 
iliac Joint  is  very  rare,  es- 
pecially in  children.  The 
symptoms  are  pain,  some- 
times radiating  down  the 
sciatic  nerve,  localized  ten- 
derness over  the  affected 
joint,  and  a  peculiar  feel- 
ing of  insecurity  in  the  pelvis  on  attempts  to  walk.  When  stand- 
ing,  the   body   is    inclined    away    from    the    diseased    side,    as   in 


Fig.  588. — Tuberculous  elbow,  fibrous  anky- 
losis, sinuses  healed.  Age  ten  years.  Three  and 
a  half  years  after  Fig.  587. 


Fig.  589. — Syphilitic  arthritis  of  left  elbow. 
Age  fourteen  years;  duration  two  years.  Also 
interstitial  keratitis  and  slight  sabre-blade 
tibia.    Orthopsedic  Hospital. 


Fig.  590.  —  Syphilitic  arthritis  of 
both  knees.  Age  thirteen  years;  dura- 
tion five  months.  Orthopsedic  Hos- 
pital. 


"  sciatica. "  Examination  shows  no  involvement  of  the  hip  or  vertebra? ; 
hyper-flexion  of  the  hip  on  the  diseased  side  occurs  to  the  normal 
extent  unless  the  knee  is  kept  extended,  when  it  will  be  impossible 


TUMORS  OF  JOINTS  545 

to  flex  the  hip  as  far  on  the  diseased  as  on  the  healthy  side,  since 
muscular  spasm  will  be  roused  by  traction  on  the  ischium  through 
the  tense  hamstrings.  Pressing  the  iliac  crests  together,  and  attempts 
at  antero-posterior  motion  in  the  pelvic  joints  cause  pain.  In  advanced 
cases  swelling  over  the  dorsal  or  pelvic  surface  of  the  joint  occurs, 
and  suppuration  may  develop,  with  sinuses  posteriorly  or  in  the 
inguinal  or  adductor  regions. 

Treatment. — Recumbency,  with  weight-extension  for  many  months, 
is  required.  No  form  of  apparatus  is  satisfactory  in  preventing 
weight-bearing  at  the  sacro-iliac  joint,  and  recurrence  of  symptoms 
is  not  unusual  when  ambulatory  treatment  is  attempted.  A  few 
recoveries  have  been  reported  after  resection  of  the  joint,  but  even 
in  adults  this  should  be  reserved  until  conservative  measures  have 
proved  ineffectual.  Picque  (1910)  reported  seven  resections  of  the 
sacro-iliac  joint  for  tuberculosis:  two  patients  were  cured,  three  were 
recovering  ("nearly  cured"),  one  died  of  cachexia,  and  the  last  had 
amyloid  degeneration  of  the  viscera  and  death  was  anticipated. 

Syphilis  of  the  Joints. — Syphilitic  arthritis  is  not  very  rare  in  cases 
of  hereditary  lues,  but  often,  especially  in  the  acquired  form  of  the 
disease,  is  not  recognized.  It  was  first  described  by  A.  Richet  (1853). 
In  its  clinical  aspects  the  disease  much  resembles  tuberculous  arthritis, 
especially  of  the  primary  synovial  type,  but  pain  is  less  severe.  The 
diagnosis  usually  is  made  from  concomitant  evidences  of  syphilis  (Figs. 
589  and  590) ,  and  is  confirmed  by  the  Wassermann  reaction  and  results 
of  antisyphilitic  treatment.  If  the  joint  is  painful,  suitable  apparatus 
should  be  provided. 

TUMORS  OF  JOINTS. 

Tumors  of  the  joints,  except  those  developed  from  the  neighboring 
bones,  are  quite  rare. 

Lipoma  Arborescens  is  the  name  given  by  Volkmann  (1882)  to 
a  synovial  or  subsynovial  growth  in  which  fatty  deposits  occur.  It 
is  observed  oftenest  in  the  knee,  along  one  side  of  the  tendo  patella?, 
but  also  occurs  in  the  shoulder.  It  is  regarded  by  Poncet,  Marsh, 
Ely,  and  Whitman  as  tuberculous  in  nature,  and  there  is  no  doubt 
that  sometimes  it  is;  but  it  is  better  to  consider  it,  with  Nichols 
(1907),  a  hypertrophic  synovial  change  which  may  occur  in  various 
joint  affections.  The  fatty  out-growth  is  more  or  less  pedunculated, 
is  palpable  through  the  skin  as  an  ill-defined  mass,  and  interferes 
with  the  functions  of  the  joint  without  producing  very  acute  symptoms. 
The  best  treatment  is  excision  of  the  growth. 

Sarcoma. — Primary  sarcoma  (endothelioma)  of  joints  is  rare.  It 
begins  in  the  synovia  or  subsynovial  connective  tissue.  Lejars  and 
Rubens-Duval  (1910)  collected  16  cases,  13  of  which  occurred  in 
the  knee.  This  is  one  of  those  neoplasms  where  transition  from  epithe- 
lioid to  sarcomatoid  tissue  is  best  observed.  The  clinical  symptoms 
somewhat  resemble  a  subacute  infectious  arthritis,  and  the  diagnosis 
usually  depends  on  microscopical  examination  of  an  excised  specimen. 
If  the  tumor  recurs  after  local  extirpation,  amputation  should  be  done. 
35 


CHAPTER  XVI. 

ORTHOPEDIC  SURGERY. 

Orthopedics,  from  the  Greek  words  dpOoz  and  ~«fC,  meaning  lit- 
erally a  straight  child,  is  that  part  of  surgery  which  deals  with  the 
correction  of  deformities,  either  congenital  or  acquired.  So  many 
surgeons,  during  the  last  fifty  years  or  more,  have  devoted  their  exclu- 
sive attention  to  this  subject,  that  the  practice  of  orthopedic  surgery 
is  now  recognized  as  a  specialty  of  equal  rank  with  gynecology  or 
genito-urinary  surgery.  In  the  limits  of  a  text-book  on  general  sur- 
gery, therefore,  it  is  manifestly  impossible  to  do  more  than  provide 
an  outline  of  the  subject,  and  inculcate  the  general  principles  which 
underlie  its  practice. 


CONGENITAL  DEFORMITIES. 

Congenital  Absence  of  Bones  is  not  very  rare.    Those  most  often 
deficient  are  the  radius,  and  the  tibia  or  fibula.    Sometimes  the  outer 

portion  of  the  foot  is  absent  along 
with  the  fibula,  or  a  portion  of  the 
hand  absent  with  the  radius.  The 
exact  diagnosis  often  depends  on 
skiagraphy.  The  hand  or  foot  de- 
viates toward  the  side  where  its 
support  is  lacking.  In  infancy 
malposition  may  be  prevented  or 
corrected  by  splints,  or  other  ap- 
paratus. Often  during  childhood 
or  adolescence  it  becomes  neces- 
sary to  operate  for  the  correction  of 
deformity,  or  to  improve  function. 
In  the  foot,  some  form  of  arthro- 
desis (p.  570)  usually  will  be  re- 
quired to  give  stability  in  walking, 
while  in  the  upper  extremity  it 
may  seem  desirable  to  lengthen  con- 
tracted muscles  and  tendons,  and 
do  osteotomy  or  resection  of  the 
existing  bone  for  cosmetic  effect, 
though  function  can  seldom  be 
improved.  Bone  transplants  (p.  248)  may  be  inserted  in  some  cases. 
Congenital  Absence  of  Muscles  (Fig.  591),  which  is  quite  rare, 
seldom  entails  much  disability;  when  it  does,  it  usually  is  possible 
to  improve  function  by  tendon  transplantation  (p.  568). 
(546) 


Fig.  591. — Congenital  absence  of 
costal  portion  of  right  pectoralis 
major,  in  a  girl  of  six  years.  No 
disability.  Slight  scoliosis.  Ortho- 
paedic Hospital. 


CONGENITAL  DEFORMITIES 


547 


Supernumerary  Fingers  or  Toes  (Polydactylism)  (Fig.  592)  usually 
require  amputation;  special  care  should  be  paid  to  hemostasis,  as 
deaths  in  infants  from  secondary  hemorrhage  have  been  reported. 
Malformations  involving  the  metacarpal  or  metatarsal  bones  seldom 
can  be  appreciated  without  a  skiagraph  (Fig.  593),  and  require  special 
types  of  operation. 


Fig.  592. — Supernumerary  digits,  six  toes  on  each  foot.  Age  seven  months.  Also 
had  six  fingers  on  each  hand,  but  the  extra  fingers  were  amputated  at  birth.  Episcopal 
Hospital. 

Webbed  Fingers  (Syndactylism)  (Fig.  594)  may  be  treated  by  several 
forms  of  plastic  operation.  Didot's  method  (1850)  is  sufficiently  indi- 
cated by  the  accompanying  figure  (Fig.  595)  and  is  suitable  for  cases 
of  syndactylism  without  any  web.  There  is  great  tendency  for  the 
web  to  re-form,  and  it  always  is  well  to  carry  the  incisions  far  down 
between  the  heads  of  the  metacarpal  bones.  For  this  reason  Agnew's 
operation  (Fig.  596)  is  preferable,  as  it  provides  a  flap  of  healthy  skin 
over  the  web. 

Congenital  Contraction  of  a  Finger  may  require  some  form  of  plastic 
operation,  after  excision  of  dense  bands  of  connective  tissue. 

Intra-uterine  Fractures. — Intra-uterine  fractures  are  to  be  distin- 
guished from  those  occurring  during  birth.  In  the  former  union  with 
deformity  and  callus  are  present  at  birth,  and  usually  there  is  a  dimple 
as  of  a  healed  wound  in  the  skin  over  the  fracture.  Its  true  nature  is 
not  known.  In  both  varieties  of  fractures  union  occurs  without  diffi- 
culty, and  almost  invariably  even  marked  deformity  becomes  spon- 
taneously corrected  within  a  year  or  two  (Fig.  597).  Immobilization 
is  necessary  only  so  long  as  the  part  is  painful. 

Congenital  Dislocations. — Congenital  Dislocation  of  the  Hip  is 
the  most  frequent  of  these  congenital  luxations.  Some  authorities 
believe  that  the  displacement  of  the  bones  may  not  always  date 
from  fetal  existence,  but  may  be  produced  by  uterine  contractions 
during  birth  (Allis,   1907),  or    after  birth  by  injudicious  attempts 


548 


ORTHOPEDIC  SURGERY 


to  extend  the  baby's  thighs;  however,  it  is  very  generally  agreed 
that  there  is  a  congenital  malformation  of  the  acetabulum  and  of  the 
head  of  the  femur  or  both,  possibly  due  to  malposition  within  the 
uterus.  The  deformity  is  more  common  in  female  (85  per  cent.)  than 
in  male  (15  per  cent.)  children,  and  more  often  unilateral  (63  per 
cent.)  than  bilateral  (36  per  cent.).     The  dislocation  is  posterior  in 


Fig.  593. — Skiagraph  of  the  left  hand  of  a  patient,  aged  nineteen  years,  showing  poly- 
dactylism  and  syndactylism.    The  right  hand  was  similarly  affected.    Episcopal  Hospital. 


the  overwhelming  majority  of  cases.  The  longer  the  dislocation 
stays  unreduced  the  more  does  the  capsule  contract  around  the  acetab- 
ulum, forming  an  hour-glass-shaped  channel  through  which  it  may 
become  impossible  to  replace  the  head.  The  acetabulum,  which  is 
shallower  than  normal,  becomes  more  so  as  life  advances  unless  the 
femoral  head  is  replaced  in  it  and  normal  weight-bearing  is  restored. 


CONGENITAL  DISLOCATIONS 


549 


Symptoms. — Frequently  nothing  abnormal  about  the  child  is  noted 
until  walking  is  attempted,  when  a  limp  is  visible  in  the  unilateral 


Fig.  594. — Webbed  fingers;  age  fourteen         Fig.  595. — Didot's  operation  for  webbed 
years.    Orthopaedic  Hospital.  fingers. 


Fig.  596.  —  Agnew's  operation 
for  webbed  fingers. 


Fig.  597. — Intra-uterine  fracture  of  the  leg.  The 
mother  fell  when  five  months  pregnant.  Baby  now 
five  months  old.  Dimple  over  site  of  fracture. 
Orthopaedic  Hospital. 


cases  (Fig.  598),  and  a  characteristic  waddle  in  the  double  dislocations. 
In  the  latter  there  also  develops  marked  lordosis  (Fig.  599),  because 
the  center  of  support  is  displaced  posterior  to  the  center  of  gravity.    If 


550 


ORTHOPEDIC  SURGERY 


the  dislocation  is  not  reduced,  deformity  and  disability  usually  increase 
with  age;  and  in  most  cases  adolescents  and  adults  must  lead  a  semi- 
invalid  existence.  The  diagnosis  is  made  from  the  history,  from  the 
symptoms  noted  above,  and  from  the  physical  examination.  This 
shows  moderate  shortening  of  the  extremity  affected  (Fig.  GOO),  eleva- 
tion of  the  trochanter  above  Nekton's  line,  and  absence  of  the  femoral 
head  from  its  socket.  By  alternately  pulling  and  pushing  on  the  fully 
extended  lower  extremity,  while  the  pelvis  is  fixed,  the  great  trochan- 
ter will  be  found  to  slide  up  and  down.     When  the  two  thighs  are 


Fig. 


598. — Congenital  dislocation  of  left  hip,  in  a  boy  of  two  years.     Limp  first  noted 
on  attempts  to  walk  at  the  age  of  fifteen  months.     Episcopal  Hospital. 


flexed  to  a  right  angle,  with  the  knees  bent,  and  the  child  on  its  back, 
the  thigh  on  the  affected  side  is  found  shorter.  There  is  diminished 
abduction,  especially  when  the  thigh  is  flexed  to  a  right  angle.  Flexion 
and  extension  are  free  and  painless,  facts  which  together  with  the 
history  readily  serve  to  distinguish  this  affection  from  traumatic  dis- 
location. In  coxa  vara  the  head  of  the  bone  is  in  the  acetabulum;  and 
in  coxalgia  there  is  an  acute  arthritis,  or  its  resultant  deformity. 
Confirmation  of  the  diagnosis  of  dislocation  is  obtained  by  skiagraphy, 
which  usually  shows  more  or  less  anteversion  of  the  head  of  the 
femur:  that  is,  instead    of  pointing   inward  toward  the  pelvis,   the 


CONGE N I TA  L  DISLOCA  TIONS 


551 


neck  of  the  femur  lies  more  nearly  in  the  sagittal  plane,  the  head  point- 
ing forward  even  when  the  lower  limb  is  not  rotated  outward. 

Treatment. — Reduction  is  best  accomplished  between  the  ages  of 
three  and  five  years.  In  very  young  children,  reduction  is  not  difficult 
to  secure  by  the  usual  methods  for  dislocation  of  the  hip  (p.  445) ;  but 
reduction  before  bony  elements  are  present  in  the  head  of  the  femur 
may  cause  irreparable  damage  to  the  growing  bone.  In  all  cases 
reduction  is  very  difficult  to  maintain  owing  to  the  shallowness  of  the 
acetabulum,  the  deformation  and  ante  version  of  the  head,  and  the 
resiliency  of  the  soft  parts.  After  the  age  of  eight  or  nine  years  it 
is  very  difficult  and  sometimes  impossible  to 
obtain  reduction  without  open  operation,  which 
is  called  by  the  Germans  the  "bloody"  as  dis- 
tinguished from  the  "bloodless"  method  of  re- 
position. Paci,  of  Pisa  (1888,  1894),  was  an  early 
exponent  of  the  bloodless  method,  which  he  sys- 
tematized, and  Lorenz  (1895)  abandoned  his 
bloody  method  to  take  up  a  modification  of 
Paci's  operation  which  he  has  popularized  all 
over  the  world.  The  child  being  etherized  and 
the  pelvis  fixed,  the  surgeon  flexes  and  then  ab- 
ducts the  thigh  until  the  adductor  tendons  become 
tense;  these  are  then  ruptured  subcutaneously  by 
blows  from  the  ulnar  side  of  the  hand,  or  by 
violent  massage.  The  limb  is  then  forcibly  hyper- 
flexed,  with  the  knee  extended,  until  it  lies  along- 
side the  body,  with  the  foot  beside  the  patient's 
head.  When  all  resisting  soft  structures  on  the 
anterior  portion  of  the  joint  have  been  ruptured, 
reduction  is  attempted:  the  trochanter  is  placed 
over  a  wedge-shaped  block,  and  by  hyperabduc- 
tion  of  the  flexed  thigh  the  surgeon  pries  the 
head  of  the  femur  into  its  socket.  The  clenched 
fist  may  be  used  as  a  fulcrum  instead  of  Lorenz's 
wedge;  but  either  method  is  liable  to  fracture  the 
cervix  femoris  (Fig.  602).  According  to  Bade 
(1909),  nerve  injury,  resulting  in  paralysis, 
has  occurred  in  67  out  of  2204  cases  of  blood- 
less reposition;  and  many  surgeons  have  produced  one  or  more  frac- 
tures of  the  femur,  myself  included  (in  a  patient  over  eight  years  of 
age).  A  much  safer  and  equally  efficient  method  is  that  of  G.  G. 
Davis  (1907),  in  which  the  patient  is  placed  prone  on  the  table,  and 
the  thigh  is  flexed  until  it  lies  alongside  the  chest,  with  the  knee  in  the 
axilla;  this  brings  the  head  of  the  femur  below  but  still  posterior  to  the 
acetabulum;  then  the  adductors  are  gradually  stretched  by  manual 
pressure  downward  on  the  great  trochanter  (Fig.  603);  when  these 
structures  have  been  stretched  enough  to  allow  the  groin  to  come 
in  contact  with  the  table,  the  head  of  the  femur  may  jump  from  the 


Fig.  599.  —  Lordosis 
in  congenital  disloca- 
tion of  both  hips;  age 
six  years.  Orthopaedic 
Hospital. 


552 


ORTHOPEDIC  SURGERY 


posterior  to  the  anterior  plane  of  the  pelvis  with  an  audible  and 
palpable  click.  If  not,  the  flexion  of  the  thigh  is  slightly  diminished 
(i.  e.,  it  is  drawn  a  little  away  from  the  chest)  and  its  abduction  is 
slightly  increased,  by  raising  the  knee  a  short  distance  from  the  table. 
Pressure  downward  on  the  trochanter  is  continued  until  the  head  of 
the  femur  can  be  felt  by  the  finger  in  the  groin.  If  reduction  cannot 
be  secured  at  the  first  attempt  without  the  use  of  unjustifiable  force, 
it  is  better  to  dress  the  limb  in  the  fullest  abduction  possible  and 
make  another  attempt  several  weeks  later  if  necessary,  after  sub- 
cutaneous  division    of   the   adductor   muscles,  close  to  the   pubis. 


Fig.  600. — -Congenital  dislocation 
of  right  hip,  in  a  girl  eight  and 
a  half  years  old.  (See  Fig.  601.) 
Orthopaedic  Hospital. 


Fig.  601. — Congenital  dislocation 
of  right  hip.  Three  and  a  half  years 
after  bloodless  reduction.  Same 
patient  as  Fig.  600.  Orthopaedic 
Hospital. 


When  reduction  has  been  secured,  this  fact  may  be  determined 

(1)  by  hearing  or  feeling  the  femoral  head  jump  into  the  acetabulum; 

(2)  by  observing  that  the  knee  can  no  longer  be  fully  extended,  since 
the  ascent  of  the  femur  from  the  posterior  plane  of  the  innominate 
bone  to  the  acetabulum  has  caused  a  relative  shortening  of  the  ham- 
strings; (3)  by  palpating  the  head  of  the  femur  in  its  socket  below 
Poupart's  ligament;  (4)  by  reproducing  the  luxation  and  again  redu- 


CONGENITAL  DISLOCATIONS 


553 


cing  it;  and  (5)  by  skiagraphy.  Sometimes  an  "anterior  transposition" 
only  is  secured :  in  this  the  head,  instead  of  jumping  into  the  acetabu- 
lum, passes  above  it  to  a  position  just  below  the  anterior  superior  spine 
of  the  ilium;  of  course  this  is  not  so  favorable  a  result  as  an  "anatomical 
reposition,"  but  it  is  better  than  a  persistence  of  the  dislocation,  since 
it  transfers  the  weight-bearing  point  to  the  centre  of  gravity. 


Fig.^602. — Fracture  of  neck  of  femur  when  hyper-abduction  is  attempted 
according  to  Lorenz's  method. 

After  reduction  the  head  of  the  femur  is  not  at  all  stable  in  its  ill- 
formed  socket,  and  the  chief  difficulty  and  tedium  in  the  care  of  these 
cases  arises  in  the  after-treatment,  in  efforts  to  prevent  relapse.  The 
limb  should  be  dressed  in  plaster  of  Paris  in  the  most  stable  position; 


Fig.  603. — G.  G.  Davis's  method  of  reducing  congenital  dislocation  of  hip. 
Orthopaedic  Hospital. 


usually  this  is  with  the  thigh  flexed  to  a  right  angle  and  abducted 
beyond  the  coronal  plane;  that  is,  so  that  the  knee  is  in  a  plane  pos- 
terior to  the  symphysis  pubis  (Fig.  604).  This,  the  "primary  position," 
called  also  the  "frog  position"  when  both  hips  are  concerned  (Fig. 
605) ,  must  be  maintained  for  from  four  to  six  months.  During  this 
time  the  child  must  be  encouraged  to  walk  about,  with  support,  as 


554 


ORTHOPEDIC  SURGERY 


weight-bearing  favors  the  deepening  of  the  acetabulum.     At  the  end 
of  this  time,  unless  reluxation  has  occurred  or  is  imminent,  the  abduc- 


Fig.  604. — Congenital  dislocation  of  right  hip;  primary  dressing.  Photographed 
two  weeks  after  operation.  Same  patient  as  Figs.  600,  601.  and  606.  Orthopaedic 
Hospital. 


Fig.  605. — Frog  position  after  reduction  of  congenital  dislocation  of  both  hips. 
Orthopaedic  Hospital. 


CONGENITAL  DISLOCATIONS 


555 


tion  and  flexion  may  be  diminished  gradually,  and  the  thigh  dressed 
in  a  less  awkward  position  (Fig.  606),  in  which  locomotion  is  easier. 
Sometimes  greater  stability  is  secured 
by  dressing  the  limb  with  the  patella 
looking  directly  forward,  without  any 
external  rotation  of  the  thigh  (Fig. 
607).  Immobilization  of  the  hip  must 
be  continued,  except  in  very  young 
children,  for  from  nine  to  eighteen 
months  after  the  primary  reposition, 
and  for  a  similar  or  longer  period  after 
any  recurrence  of  dislocation  and  sec- 
ondary reposition.  After  this  time  ex- 
ternal support  may  be  discontinued, 
and  gentle  passive  motion  and  massage 
may  be  prescribed.  The  younger  the 
child,  the  sooner,  as  a  rule,  can  external 
support  be  dispensed  with,  and  the 
sooner  will  function  return. 

In  older  children  prolonged  traction, 
in  gradually  increasing  abduction, 
should  be  employed  for  several  weeks 
before  attempts  at  reposition  are  made. 
Churchman  (1919)  has  devised  a  cir- 
cular gas-pipe  frame  attached  to  the 
bedstead,  which  allows  this  method 
to  be  applied  efficiently  and  sys- 
tematically; and  by  its  aid  has  secured  spontaneous  reduction.  If 
reluxation  recurs  persistently,  and  in  cases  where  bloodless  reposi- 


Fig.  606. — Congenital  dislocation 
of  right  hip  in  walking  cast.  Same 
patient  as  Figs.  600,  601,  and  604. 
Orthopaedic  Hospital. 


Fig.  607. — Secondary  position  in  congenital  dislocation  of  the  hip.     Note  the 
bed-pan  in  position  beneath  the  frame.     Episcopal  Hospital. 


556 


ORTHOPEDIC  SURGERY 


tion  is  impossible ,  a  resort  to  open  operation  usually  is  proper.  The 
best  approach  is  by  Lambotte's  incision,  from  the  anterior  superior 
iliac  spine  to  the  great  trochanter,  thence  downward  and  forward, 
turning  the  flap  (formed  of  tensor  fascise  lata?)  forward.  In  all  cases 
the  capsule  is  widely  opened,  preserving  the  Y-ligament;  and  the  ace- 
tabulum is  cleared  out  sufficiently  to  hold  the  head  of  the  femur. 
Structures  preventing  reduction  should  be  divided;  but  in  adults,  where 
utmost  efforts  sometimes  fail  to  secure  reduction,  it  may  be  sufficient 
to  form  a  new  socket  above  the  acetabulum  (G.  G.  Davis,  1908).  A 
certain  measure  of  relief  will  be  secured  if  the  head  of  the  femur  becomes 
more  firmly  fixed,  in  any  position,  than  it  was  before  operation 

Birth  Injuries  of  the  Shoulder. — These  were  formerly  confused  with 
congenital  dislocations  of  the  shoulder,  which  probably  do  not  exist; 
and  with  brachial  birth  yahies  which  are  probably  only  incidental  not 

essential  lesions.  It  was  formerly 
held  that  the  cause  was  direct  pres- 
sure on  the  brachial  plexus  by  for- 
ceps in  delivery  (which  is  admittedly 
rare),  or  stretching  and  laceration 
of  the  plexus  from  attempts  to 
deliver  a  shoulder  by  injudicious 
traction  on  the  head  or  in  delivery  of 
the  aftercoming  head.  But  T.  T, 
Thomas  (1910)  proposed  the  theory 
that  lesions  of  nerves  were  due  to 
their  being  caught  in  effusion  of 
blood  and  lymph  and  that  the  essen- 
tial lesion  is  injury  to  the  shoulder^ 
joint,  produced  by  direct  pressure  on 
the  humerus  and  acromion  by  the 
maternal  pelvis,  the  arms  being 
flexed  and  adducted  at  the  shoulder 
(1914).  This  produces  a  posterior 
subluxation  or  complete  dislocation. 
The  usual  deformity  is  characteristic  (Fig.  608),  the  arm  being  in 
internal  rotation,  and  there  being  apparent  paralysis  of  muscles  sup- 
plied by  the  suprascapular,  musculocutaneous,  circumflex,  and  some- 
times radial  nerves,  all  of  which  lie  close  to  the  joint;  while  the  muscles 
supplied  by  the  subscapular  nerves,  the  median,  ulnar,  anterior  thoracic 
nerves  and  others  not  lying  close  to  the  joint,  escape  (Ashhurst,  1917). 
The  hand  is  little  affected,  but  supination  and  flexion  of  the  forearm 
are  imperfect  or  entirely  absent.  This  corresponds  to  the  upper  arm 
type  of  brachial  paralysis  described  by  Duchenne  (1872)  and  Erb  (1874), 
the  lesion  being  in  the  outer  cord  (fifth  and  sixth  cervical  nerves)  of 
the  brachial  plexus.  The  "lower  arm"  type  (Dejerine-Klumpke),  and 
paralysis  of  the  entire  extremity  are  rare. 

Treatment. — Treatment  consists  in  rest  in  a  sling  until  acute  pain  is 
absent,  then  in  passive  movements  (active  also  so  far  as  possible)  to 


Fig.  608. — Birth  injury  of  the  left 
shoulder,  in  a  boy  aged  seventeen 
months.  Typical  posture.  Ortho- 
paedic Hospital. 


CONGENITAL  DISLOCATIONS 


557 


overcome  the  tendency  to  contracture  in  adduction  and  internal  rota- 
tion. If  subspinous  dislocation  exists,  it  should  be  reduced  at  about 
six  months  of  age  by  a  method  analogous  to  that  of  G.  G.  Davis  for 


Fig.  609. — Birth  injury  to  shoulder  in  a  boy  aged  five  and  one-half  years;  the  typica 
disability  is  that  the  patient  cannot  get  his  hand  to  his  mouth,  even  with  marked 
abduction  of  the  shoulder  joint.     Episcopal  Hospital. 

congenital  dislocation  of  the  hip,  and  the  arm  maintained  in  abduction 
and  external  rotation  for  three  months.  If  the  child  does  not  come 
under  observation  until  the  age  of  three  years  or  older,  it  usually  is 
necessary  to  resort  to  arthrotomy  to  secure  reduction  (Figs.  609  and 


Fig.  610. — Birth  injury  to  shoulder  two  years  after  open  operation.  The  dislocation 
has  been  reduced,  and  external  rotation  has  been  restored,  and  the  hand  can  now  be 
put  to  the  mouth.     Episcopal  Hospital. 


610).  This  is  best  done  through  Senn's  incision  (p.  253).  In  late  cases 
without  dislocation  much  benefit  may  result  from  tenotomy  of  the  con- 
tracted muscles,  especially  the  subscapularis  and  pectoralis  major. 


r,:,s 


ORTHOPEDIC  SURGERY 


Congenital  Elevation  of  the  Scapula,  Sprengel's  Deformity  (1891). — 
The  upper  extremity  develops  as  an  appendage  of  the  cervical  spine, 
and  if  normal  descent  of  the  scapula  fails  to  occur,  it  remains  in  the 
cervico-dorsal  region,  more  or  less  deformed,  often  being  fixed  to  the 
vertebral  spines  by  a  process  of  bone  or  cartilage.  A.  E.  Horwitz 
(1908)  studied  136  cases.  In  a  patient  under  my  own  care  (Fig.  Gil), 
who  also  presented  congenital  scoliosis  and  absence  of  several  ribs, 
marked  improvement  resulted  from  open  section  of  the  muscles 
attached  to  the  vertebral  border  of  the  scapula,  depression  of  the 
scapula,  and  re-attachment  of  the  rhomboids  to  the  upper  angle  of  the 
bone  (Fig.  612). 


Fig.  611. — Congenital  elevation  of  left 
scapula  in  a  boy  of  three  years;  before 
operation.     Orthopaedic  Hospital. 


Fig.  612. — Congenital  elevation  of 
left  scapula,  three  months  after  opera- 
tion.    Orthopaedic  Hospital. 


Congenital  Dislocation  of  the  Knee  is  quite  rare,  and  usually  is 
anterior  in  direction,  the  leg  being  hyperextended  on  the  thigh.  The 
patella  may  be  absent.  The  use  of  splints  or  orthopedic  apparatus 
usually  secures  a  return  to  the  normal  position,  with  moderate  range 
of  flexion,  before  the  age  for  walking  arrives. 

Congenital  Talipes. — The  cause  of  congenital  foot  deformities  is 
unknown,  though  they  often  are  attributed  to  malposition  in  the 


CONGENITAL   TALIPES 


559 


uterus.  The  hands  sometimes  are  the  seat  of  similar  deformities  (Club 
Hands) .  The  deformity  may  affect  one  or  both  feet.  There  are.several 
distinct  types  of  deformity,  though  usually  more  than  one  is  present. 
Talipes  Equinus  is"pointed  toe"  deform- 
ity in  which  the  front  of  the  foot  is  de- 
pressed and  the  heel  elevated,  the  patient 
walking  on  the  toes,  as  a  horse,  whence 
the  name.  In  Talipes  Calcaneus  the  heel 
is  depressed  and  the  toes  elevated.  In 
Talipes  Varus  the  anterior  part  of  the 
foot  is  adducted,  and  the  foot  is  inverted 
(supinated);  the  inner  border  of  the 
sole  is  shortened  and  elevated,  and  the 
patient  walks  on  the  outer  border.  In 
Talipes  Valgus  the  anterior  part  of  the 
foot  is  abducted,  the  foot  is  everted 
and  pronated,  the  sole  is  flat,  and  the 
inner  border  of  the  foot  is  convex.  In 
Talipes  Cavus  or  Arcuatus  .("hollow 
foot")  the  arch  of  the  foot  is  high,  and 
the  foot  is  shortened  antero-posteri- 
orly,  without  being  either  pronated  or 
supinated. 

At  birth,  there  seldom  is  appreciable 
bony  deformity,  but  contractures  of 
tendons  and  ligaments  as  well  as  of  the 
skin  and  subcutaneous  tissues  are  pres- 
ent. If  the  deformity  is  not  overcome 
while  the  bones  are  soft,  these  will  become  deformed,  adapting  their  form 
to  the  altered  function  required  by  weight-bearing  and  locomotion. 

Equino-varus. — The  most 
frequent  combination  of 
congenital  deformities  is 
that  of  equinus  and  varus, 
forming  the  ordinary  "club- 
foot" (Fig.  614) ;  there  often 
is  slight  earns  as  well.  The 
feet  turn  in,  the  soles  face 
each  other,  the  tibial 
border  of  the  sole  is  con- 
cave and  shortened,  and 
the  heel  is  elevated.  There 
is  no  natural  tendency  for 
the  deformity  to  correct  it- 
self; on  the  contrary,  if  pa- 
tients are  neglected  and  allowed  to  walk,  the  deformity  constantly 
increases  until  in  extreme  cases  they  may  have  to  walk  on  the  dorsum 


Fig.  613.  —  Congenital  talipes 
equinus,  with  slight  cavus  deform- 
ity in  a  boy  of  thirteen  years. 
Orthopaedic  Hospital. 


Fig.  614. — Congenital  equino-varus  (bilateral),  age 
seven  months.  (See  Fig.  615.)  Orthopaedic  Hospita 


5G0 


ORTHOPEDIC  SURGERY 


of  the  foot  (Fig.  615).  The  tibialis  anticus  and  posticus  are  short, 
and  keep  the  foot  inverted;  the  tendo  Achillis  raises  the  heel;  the 
plantar  fascia  is  contracted  and  arches  the  foot,  and  the  flexors  of 
the  toes  aid  in  causing  cavus  deformity.  The  calcaneum  long  remains 
small  and  ill-formed,  and  the  calf  muscles  are  poorly  developed,  because 
of  disuse;  and  the  extensors  of  the  toes  and  the  peronei,  which 
work  at  marked  disadvantage,  are  weak  and  totally  unable  to  over- 
come the  deformity. 

Treatment. — In  earliest  infancy  manual  correction  alone  may  suffice, 
if  it  is  applied  intelligently  and  at  least  twice  daily.  Holding  the 
leg  bones  at  the  malleoli  in  one  hand,  the  other  hand  forcibly  abducts 
the  foot,  so  as  to  stretch  the  shortened  tissues  on  the  inner  side  of  the 
sole.    This  is  repeated  from  ten  to  twenty  times,  morning  and  night. 

When  the  adduction  can  be  over- 
come, and  the  foot  brought  into  a 
straight  line  with  the  leg,  but  not 
before,  attempts  are  made  to  bring 
the  heel  down  by  dorsi-flexing  the 
foot  in  the  sagittal  plane.  By  no 
means  should  the  tendon  of  Achilles 
be  divided  so  long  as  there  remains 
the  slightest  tendency  to  varus; 
without  the  calcaneum  as  a  fixed 
point  (made  so  by  the  attachment 
of  the  Achilles  tendon)  it  is  impos- 
sible to  overcome  by  manipulation 
the  adduction  of  the  foot.  From  the 
age  of  a  few  weeks  until  the  child 
begins  to  stand,  the  foot  should  be 
held  in  the  best  position  obtainable 
at  each  manipulation  by  being  ban- 
daged to  a  posterior  right-angled 
splint,  or  in  plaster  of  Paris.  If  plas- 
ter of  Paris  is  used,  the  case  should 
be  renewed  every  two  or  three  weeks  and  the  foot  put  up  again  in  the 
improved  position  secured  by  renewed  manipulation.  Sometimes  it  is 
necessary  to  anesthetize  the  baby  to  apply  manipulation  effectively. 
If  this  treatment  is  faithfully  carried  out  there  are  very  few  cases 
of  club  feet  in  which  the  feet  will  not  be  in  sufficiently  good  position 
for  weight-bearing  when  the  age  for  walking  arrives.  At  this  stage 
braces  may  be  applied,  to  be  worn  night  as  well  as  day,  but  removed 
daily  for  washing  and  manipulation;  and  these  must  be  continued 
until  there  is  no  further  tendency  to  relapse.  The  main  factors  in  such 
apparatus  are  a  strong  laced  shoe,  open  to  the  toe,  so  that  the  foot 
can  be  inserted  easily;  an  instep  strap  to  hold  the  foot  against  the 
sole,  and  keep  the  heel  from  rising;  side  irons  to  prevent  inversion  of 
the  foot;  and  an  elastic  strap  from  the  outer  side  of  the  foot  to  the 


Fig.  615. — -Inveterate  varus.  Same 
patient  as  Fig.  614,  three  years  later. 
Has  received  no  treatment;  walks  on  the 
dorsum  of  his  feet.  Orthopaedic  Hospital. 


CONGENITAL   TALIPES 


561 


outer  side  iron,  to  keep  the  ankle  dorsi-flexed  and  the  foot  everted. 
Apparatus  is  not  designed  to  overcome  deformity,  but  acts  merely  as 
do  splints  in  the  case  of  fractured  bones,  to  maintain  proper  position 
after  this  has  been  secured  by  other  means.     These  braces  (as  all 


Fig.  616.  —  Bilatera'  equino-varus 
(congenital).  Age  seven  years.  Re- 
lapsed case,  from  neglect  of  treatment. 
Orthopaedic  Hospital. 


Fig.  617. — Relapsed  varus.  Rear  view 
of  patient  in  Fig.  616.  (See  Fig.  622.) 
Orthopaedic  Hospital. 


other  orthopedic  apparatus)  will  require  constant  oversight  and 
adjustment,  and  this  must  not  be  shirked  by  the  surgeon  who  under- 
takes the  treatment  of  such  cases.  Braces  present  the  great  advan- 
tage over  gypsum  that  thev  permit  muscular  action,  and  so  favor 


Fig.  618. — Club-foot  wedge  in  use,  overcoming  varus.     Orthopaedic  Hospital. 


development  of  the  limb.  Usually  they  should  extend  to  mid-thigh, 
for  greater  security;  and  where  internal  rotation  of  the  foot  is  per- 
sistent, it  may  be  necessary  to  add  a  pelvic  band,  so  as  to  have  some 
fixed  point  by  which  to  evert  the  entire  lower  extremity. 


36 


562 


ORTHOPEDIC  SURGERY 


In  cases  in  which  proper  treatment  has  been  neglected,  and  in 
relapsed  cases  (Figs.  616  and  617),   mere  manipulation  usually  is 


Fig.  619. — G.  G.  Davis's  tarsoclast  in  use.     Orthopaedic  Hospital. 


Fig.  620. — Use  of  G.  G.  Davis's  lever  to  stretch  tendo  Achillis.   Orthopaedic  Hospital. 


powerless  to  overcome  the  deformity.  Here  the  patient  must  be 
anesthetized,  and  more  forcible  stretching  done,  as  indicated  in  the 
accompanying  illustrations  (Figs.  618,  619,  620  and  621).    The  foot  is 


CONGENITAL  TALIPES 


563 


dressed  in  over-corrected  position  in  plaster  of  Paris  and  the  patient 
stays  in  bed  several  days  after  the  operation,  and  for  the  first  twenty- 


^m 

IS       4'jj 

fr 

^^^w    '     ^^ 

^^^^^~*~ 

BBBpBW^^ . 

*~ 

i 

■HI 

Fig.  621. — G.  G.  Davis's  varus  machine  in  use.     Orthopaedic  Hospital. 

four  hours  the  foot  is  kept  elevated  to  prevent  edema.    Walking  in 
the  gypsum  case  is  then  allowed.    If  the  stretching  (redressement  force) 

is  skilfully  done,  evil  consequences 
are  very  unusual,  though  rarely  a 
superficial  slough  may  form  over  the 
dorsum  of  [the  foot.  The  plantar 
fascia  often  is  tense,  and  usually 
should  be  divided;  but  tenotomy  of 
the  tendo  Achillis  or  other  tendons 
seldom  is  advisable.  Tenotomy  usu- 
ally is  done  by  the  subcutaneous 
method  (Stromeyer,  1831):  a  punc- 
ture is  made  by  a  sharp-pointed 
tenotome  (Fig.  623)  just  to  one  side 
of  the  tense  tendon  and  where  it 
is  most  accessible;  a  blunt-pointed 
tenotome  is  then  inserted  beneath 
the  tendon,  and  while  this  is  kept 
taut,  it  is  divided  from  within  out- 


Fig.  622. — Bi'ateral  equino-varus 
after  use  of  instruments  shown  in  Figs. 
618  to  620.  Same  patient  as  Figs.  616 
and  617.     Orthopaedic  Hospital. 


Fig.  623. — Sharp  and  blunt-pointed 
tenotomes. 


ward  by  a  gentle  sawing  motion;   any  oozing  of  blood  is  checked 
by  pressure  and  an  aseptic  dressing  applied  with  the  limb  as  much 


564 


ORTHOPEDIC  SURGERY 


over-corrected  in  position  as  is  possible;  and  this  position  is  maintained 
by  a  fixed  dressing  for  four  to  six  weeks.  The  tendo  Achillis  is  divided 
about  an  inch  above  its  insertion;  the  tibialis  anticus  below  the  annular 
ligament;  the  tibialis  posticus  between  the  internal  malleolus  and  its 
point  of  insertion;  and  the  peroneal  tendons  behind  and  above  the 
external  malleolus. 


Fig.  624. — Inveterate  equino-varus  in  a  woman  aged 
twenty-eight  years.  No  treatment  since  birth.  Ortho- 
paedic Hospital. 


Fig,  625. — Result  of 
astragalectomy.  Same 
patient  as  Fig.  624. 


In  cases  in  which  bony  deformity  has  developed,  which  cannot  be 
overcome  by  forcible  manipulation  as  above  indicated,  it  may  be 
necessary  to  do  some  formal  cutting  operation.  In  most  cases  in 
children  or  adults,  the  best  method  of  overcoming  the  deformity  is  to 


Fig.  626, 


-Bilateral  congenital  talipes  valgus.     Age  two  and  a  half  years. 
Orthopaedic  Hospital. 


do  cuneiform  tarsectomy,  or  wedge-shaped  resection  of  the  tarsus  CR. 
Davy,  1881) :  in  this  operation  a  wedge  of  bone  (regardless  of  the 
outlines  of  the  individual  bones),  with  its  base  on  the  dorsum  and 
its  apex  on  the  sole,  is  removed  from  across  the  tarsus;  the  portion 
excised  being  sufficiently  large  to  allow  over-correction  of  the  deform- 
ity.   It  is  often  well  to  combine  this  with  transplantation  of  the  tibialis 


PARALYTIC  DEFORMITIES 


565 


anticus   to  the  outer  side  of  the  tarsus.     Astragalectomy  (Lund,  of 

London,  1872),  which  is  preferred  by  many  surgeons,  is  more  difficult 

of    execution,    and    leaves    a    less 

shapely  foot  than  does  cuneiform 

tarsectomy  but  may  be  indicated 

by    the  nature   of   the  deformity 

(Figs.  624  and  625). 

Other  forms  of  congenital  talipes 
(Fig.  626),  as  well  as  club-hand, 
contracted  knee  (Fig.  627),  etc.,  are 
so  rare  that  it  seems  unnecessary 
to  discuss  them  here,  as  the  prin- 
ciples of  treatment  are  the  same 
as  in  equino-varus. 

PARALYTIC  DEFORMITIES. 

Acute  Anterior  Poliomyelitis. — 
Paralytic  Talipes. — Most  of  the  para- 
lytic deformities  which  require 
orthopedic  treatment  are  the  result 
of  "infantile  paralysis,"  though 
cases  occasionally  are  encountered  the  effect  of  cerebrospinal  menin- 


Fig.  627. — Congenital  club-feet  and 
contracture  of  knee.  Age  three  years. 
Episcopal  Hospital. 


gitis,   diphtheria,   or    other  rarer 


infections.  The  vast  majority  of 
cases  of  infantile  palsy  involve  one 
or  both  lower  extremities,  espe- 
cially the  feet.  The  extent  of  the 
paralysis  is  very  variable;  it  may 
affect  only  one  muscle  group,  or  a 
single  muscle;  or  it  may  affect  both 
lower  extremities  in  their  entirety, 
forcing  the  child  to  walk  on  his 
hands,  using  the  feet  merely  as 
props  (Fig.  628),  or  occasionally 
inducing  a  quadrupedal  gait;  or 
the  trunk  also  may  be  paralyzed, 
rendering  the  child  helpless.  In- 
fantile palsy  affecting  one  side  of 
the  back,  is  an  occasional  cause 
of  scoliosis  (Fig.  645).  In  some 
cases  there  is  only  slight  tendency 
to  contractures  of  the  unparalyzed 
muscles,the  paralyzed  part  remain- 
ing entirely  flaccid;  while  in  others, 
contractures  are  an  early  and  prom- 
inent symptom.  In  nearly  every 
case  deformity  eventually  develops. 
When  it  has  been  ascertained  that  paralysis  exists,  it  is  important 
to  institute   mechanical  treatment   at   once,  to   prevent,  so  far  as 


Fig.  628. — Infantile  palsy  of  both  lower 
extremities.  Position  assumed  in  walk- 
ing on  hands.  Age  four  years.  Ortho- 
paedic Hospital. 


566 


ORTHOPEDIC  SURGERY 


possible,  the  development  of  deformity,  and  to  encourage  return 
of  function.  Even  the  weight  of  the  bed-clothes  on  the  toes  may  be 
injurious,  predisposing  to  equinus  deformity.  The  foot  should  be 
supported  at  a  right  angle  with  the  leg,  and  the  knee  and  hip  should 
be  kept  fully  extended,  by  suitable  splints  or  apparatus.  Not  until 
acute  symptoms  have  been  absent  for  some  weeks,  should  massage 
and  electric  treatment  be  employed;  use  of  the  limb  should 
now  be  encouraged,    provided    that   proper  posture  is  maintained. 

Usually  after  a  month  or  two  the 
extent  of  the  paralysis  will  be  fairly 
well  defined,  but  under  conserva- 
tive measures,  further  improvement 
may  occur  for  two  or  three  years.  If 
proper  treatment  (orthopedic  support, 
massage,  electricity)  has  been  insti- 
tuted promptly,  and  faithfully  pur- 
sued, usually  there  will  be  no  further 
improvement  after  the  lapse  of  this 
time.  But  in  all  cases  where  such 
treatment  has  not  been  employed,  the 
surgeon  should  delay  resort  to  opera- 
tive methods  until  trial  has  been  made 
of  mechanical  support,  massage,  etc., 
for  at  least  one  year. 

If  deformity  develops  from  neglect 
of,  or  in  spite  of,  proper  support  by 
apparatus,  various  forms  of  paralytic 
talipes  may  be  present.  These  are  dis- 
tinguished from  the  deformities  of 
congenital  talipes  by  the  history  of 
their  being  acquired,  usually  during 
the  second  or  third  year  of  life,  as  the 
result  of  an  acute,  even  if  slight,  febrile  attack,  after  which  the  child 
began  to  limp;  by  their  flaccid  character,  some  muscles  being  notice- 
ably paralyzed,  while  others  by  overaction  cause  persistent  deviation 
of  the  foot;  by  reactions  of  degeneration  in  the  paralyzed  muscles 
when  their  electrical  con- 
tractility is  investigated 
(these  never  exist  in  con- 
genital talipes) ;  and  by 
marked  atrophy  of  the 
paralyzed  limb. 

The  most  frequent  de- 
formity is  equino-varus,  due 
to  paralysis  of  the  peroneal 
muscles,   often  associated 

With   loss  of  power   in   the       ,  flG-  630.— Paralytic  equinus,  age  twenty  years, 
,        *         ,.    .,  deformity  growing  steadily  worse  since  childhood, 

extensor  longUS  dlgltoriim      Orthopedic  Hospital. 


Fig.  629. — Paralytic  foot-drop,  in 
a  girl  of  fourteen  years.  Orthopaedic 
Hospital. 


PARALYTIC  DEFORMITIES 


567 


and  extensor  longus  hallucis;  the  tibialis  anticus  and  posticus  act 
as  strong  inverters  of  the  foot,  and  the  unopposed  flexors  and 
calf  muscles  maintain  foot-drop   (Fig.  629),  producing  a  potential 


Fig.  631. — Paralytic  varus  before 
operation.  Age  fifteen  years;  dura- 
tion eight  years.  (See  Fig.  632.) 
Orthopaedic  Hospital. 


Fig.  632.— Patient  shown  in  Fig.  631,  after 

transplantation    of    tibialis  anticus    to    base 

of    fifth    metatarsal   bone.  Orthopaedic  Hos- 
pital. 


Fig.  633. — Paralytic  calcaneus,  showing  attitude  assumed  in  walking.  Aged  twelve 
years;  duration  eight  years.  Left  foot  assumed  similar  attitude  as  soon  as  any  attempt 
at  motion  was  made,  but  patient  could  not  balance  himself  long  enough  with  both  feet 
in  action  for  a  photograph  to  be  taken.     (See  also  Fig.  634.)     Orthopaedic  Hospital. 


;,c„s 


ORTHOPEDIC  SURGERY 


equinus  which  it'  long  uncorrected  may  become  a  fixed  deformity 
(Fig.  0:>0).  In  other  cases  there  is  no  marked  contracture  of  the 
active  muscles,  but  owing  to  the  paralysis,  the  foot  easily  turns  into 
a  position  of  extreme  deformity  (Fig.  031),  rendering  locomotion 
almost  impossible  without  apparatus.  Paralytic  Calcaneus  (Fig.  033) 
is  due  to  paralysis  of  the  calf  muscles;  the  unopposed  extensors  cause 
the  toes  to  fly  into  the  air  at  each  step;  sometimes  there  is  dislocation 

of  the  peroneal  tendons  anterior  to  the 
external  malleolus.  Calcaneus  deformity 
usually  is  combined  with  marked  cavus 
(Fig.  034),  though  this  may  exist  alone, 
from  contracture  of  the  plantar  fascia 
and  extensors  of  the  toes,  when  the  short 
foot  muscles  (interossei  and  lumbricals) 
have  been  paralyzed  (Fig.  030).  Para- 
lytic Valgus  (Fig.  635)  is  much  more 
common  than  a  similar  congenital  de- 
formity; usually  the  two  tibial  muscles 
are  paralyzed,  and  sometimes  the  flexors 
of  the  toes  as  well.  Usually  the  peronei 
are  contracted. 

In  many  cases  correction  of  deformity, 
by  forcible  manipulation,  tendon  length- 
ening, etc.,  may  enable  weak  but  not 
completely  powerless  muscles  to  recover 
nearly  normal  strength. 

When  it  has  been  ascertained  that  no 
further  recovery  of  power  is  to  be  ex- 
pected the  aim  of  the  surgeon  should  be 
to  devise  some  means  by  which  apparatus  may  be  discarded.  Whenever 
there  are  a  sufficient  number  of  healthy  muscles  for  the  purpose,  it  is 
possible,  by  changing  the  points  of  insertion  of  one  or  more,  so  to  distrib- 
ute the  muscular  power  which  remains  as  to  secure  to  the  patient  a 
well  balanced  foot.  This  operation  is  known  as  Tendon  Transplantation. 
It  seldom  is  advisable  to  employ  it  before  the  age  of  six  years,  since 
before  this  age  it  is  very  difficult  to  be  certain  which  muscles  are 
functionally  active,  because  this  is  a  point  ascertained  much  more 
accurately  by  clinical  observation  than  by  investigation  of  the  elec- 
trical reactions.  Before  tendon  transplantation  is  attempted,  it  is 
important  to  overcome  all  deformity,  and  this  may  require  repeated 
manipulation  under  an  anesthetic,  redressement  force  (as  in  congenital 
talipes,  p.  502),  or  even  tenotomies;  only  when  the  foot  can  be  held 
in  the  over-corrected  position  by  the  pressure  of  one  finger,  will  it 
be  safe  to  resort  to  operation.  The  best  method  of  tendon  trans- 
plantation is  the  periosteal  insertion  of  Lange  (1898);  this  may  be 
succinctly  described  by  a  concrete  example,  namely,  the  transplan- 
tation of  the  tibialis  anticus  to  the  base  of  the  fifth  metatarsal 
bone,  for  the  relief  of  varus  due  to  paralysis  of  the  peroneal  muscles. 


Fig.  G34. — Paralytic  calcaneus, 
showing  secondary  cavus,  when 
toes  were  forcibly  flexed.  Same 
patient  as  Fig.  633. 


PARALYTIC  DEFORMITIES 


569 


Under  Esmarch  anemia  the  tibialis  anticus  is  divided  at  its  insertion, 
and  is  drawn  out  of  its  sheath  through  a  second  incision  made  over 
its  course  above  the  annular  ligament;  a  subcutaneous  channel  is 
then  burrowed  from  above  the  annular  ligament  to  the  tuberosity 
of  the  fifth  metatarsal  bone,  and  through  a  third  incision  at  the 
latter  point  the  tendon  of  the  tibialis  anticus  is  drawn  down,  and  under 
tension  is  sutured  to  the  periosteum  by  several  mattress  sutures 
of  strong  chromic  catgut.  The  foot  is  immobilized  in  over-corrected 
position  (valgus),  in  gypsum,  for  eight  weeks;  function  is  then  grad- 
ually resumed.  The  tibialis  anticus  being  now  inserted  on  the  outer 
side  of  the  foot  will  act  as  an  everter,  largely  replacing  the  paralyzed 
peronei,  and  rendering  the  further  use  of  apparatus  unnecessary. 


Fig.  635. — Paralytic  valgus,  age  seven 
years;  treated  by  tendon  transplantation. 
Orthopaedic  Hospital. 


Fig.  636.  —  Paralytic  cavus,  age 
eleven  years,  showing  over-action  of 
the  extensor  longus  hallucis.  Ortho- 
paedic Hospital. 


In  similar  manner,  for  other  deformities,  various  other  tendons 
may  be  transplanted,  as  will  occur  to  the  mind  of  any  ingenious 
surgeon.  For  paralytic  valgus  it  is  best  to  transplant  the  extensor 
longus  hallucis  to  the  insertion  of  the  tibialis  anticus;  when  the  exten- 
sor longus  hallucis  is  paralyzed  also,  one  of  the  peronei  may  be  trans- 
ferred to  the  insertion  of  the  tibialis  anticus,  or  if  the  extensor  longus 
digitorum  is  active,  the  distal  end  of  the  tibialis  anticus  (divided 
above  the  annular  ligament)  may  be  sutured  to  this  healthy  ten- 
don. For  paralytic  cavus,  the  extensor  longus  hallucis,  which 
is  usually  the  deforming  factor  (Fig.  636),  may  be  attached  to 
the  head  of  the  first  metatarsal.  For  paralytic  calcaneus  the  peronei 
and  tibialis  posticus  may  be  transplanted  into  the  insertion  of  the 
tendo  Achillis  (Figs.  633  and  634),  though  in  most  cases  transverse 
horizontal  section  of  the  tarsus  (see  p.  571)  is  preferable.  For  paralysis 
of  the  quadriceps  femoris  one  or  more  of  the  hamstrings  may  be  trans- 


570  ORTHOPEDIC  SURGERY 

planted  into  the  patella;  and  for  paralysis  of  the  internal  rotators  of 
the  thigh,  the  tensor  fasciae  femoris  may  be  transplanted  into  the  great 
trochanter  (G.  G.  Davis,  1911). 

In  many  cases  it  is  possible  by  shortening  paralyzed  tendo?is  to 
enable  them  to  act  as  ligaments  in  maintaining  better  position,  or 
when  slight  power  remains,  to  enable  them  to  use  it  to  better  advan- 
tage. Or  the  proximal  end  of  the  tendon  of  an  entirely  paralyzed 
muscle  may  be  attached  to  bone,  thus  converting  the  tendon  into  a 
ligament  (Sangiorgi,  1901,  Gallie,  1913). 


Fig.  637. — Paralytic  flail-foot,  age  eighteen  years;  duration  fourteen  years. 
Orthopaedic  Hospital. 

Nerve  Anastomosis  has  been  employed  in  some  cases  of  paralytic 
deformities  of  the  feet,  but  not  with  much  success.  It  should  be 
reserved  for  those  cases  in  which  the  entire  distribution  of  one  nerve 
is  paralyzed,  but  in  which  the  entire  distribution  of  a  neighboring 
nerve  is  intact. 

Arthrodesis. — When  so  many  muscles  are  paralyzed  that  none  are 
available  for  transplantation,  it  is  possible  to  convert  a  "dangle-foot" 
with  flail-joints  (Fig.  637)  into  a  firm  and  useful  support  by  pro- 
ducing an  artificial  ankylosis.  This  operation,  known  as  arthrodesis 
(Fig.  638),  should  not  be  undertaken  before  the  age  of  eight  or  nine 
years,  since  the  bones  of  younger  patients  are  still  too  cartilaginous  for 
firm  union  to  follow  a  joint  resection.  For  "footdrop,"  arthrodesis  of 
the  ankle-joint  is  done;  through  a  small  transverse  incision  over  the 


PARALYTIC  DEFORMITIES 


571 


front  of  the  joint,  displacing  the  tendons,  the  articulating  surfaces  of 
the  astragalus,  tibia,  and  fibula  are  removed.  For  lateral  mobility, 
subastragalar  arthrodesis  is  done;  in  most  cases  a  single  external 
incision,  above  the  peroneal  tendons,  is  sufficient  to  remove  the  articu- 
lating surfaces  of  astragalus  and  calcaneum,  as  well  as  those  of  astrag- 
alus and  scaphoid  (Fig.  179).  The  wounds  are  closed  without  drainage, 
and  the  foot  is  fixed  in  gypsum  for  eight  weeks,  when  walking  may  be 
resumed;  but  a  light  brace  should  be  worn  for  a  few  months  more. 


Fig. 


638. — Result  of  arthrodesis  of  ankle  and  subastragalar  joints. 
Orthopaedic  Hospital. 


(See  Fig.  637.) 


For  cases  of  calcaneus,  calcaneo-cavus,  or  calcaneo-valgus,  no  opera- 
tion is  as  satisfactory  as  the  transverse  horizontal  section  of  the  tarsus 
devised  by  G.  G.  Davis  (1913);  this  combines  a  subastragalar  arthro- 
desis with  a  shifting  backward  of  the  foot  on  the  leg  bones,  the  hori- 
zontal section  passing  through  the  subastragalar  joint  posteriorly  and 
emerging  on  the  dorsum  of  the  tarsus  beneath  the  extensor  tendons. 
This  displacement  elongates  the  heel,  and  shifts  the  weight  of  the  body 
forward  to  the  apex  of  the  hollow  sole.  Transplantation  of  the  peroneal 
tendons  into  the  calcaneum  may  be  a  useful  addition. 


572 


ORTHOPEDIC  SURGERY 


Fig.  G39. — Infantile  palsy  of  right  arm. 
Children's  Hospital. 


Infantile  Paralysis  of  the  Upper  Extremity  (Fig.   639),  much  rarer 
than  paralytic  affections  of  the  lower  limbs,  is  treated  on  the  same 

general  principles.  Transplan- 
tation of  muscles  has  been  done 
chiefly  at  the  shoulder  where 
a  portion  of  the  trapezius  or  of 
the  pectoralis  major  has  been 
used  to  supplement  the  deltoid. 
Nerve  anastomosis  has  given 
no  better  results  than  in  the 
leg. 

Cerebral  Palsies. — These  re- 
sult from  cortical  or  meningeal 
hemorrhages,  or  from  congen- 
ital defects,  such  as  poren- 
cephalon.  Spasticity  is  their 
main  characteristic,  and  by  this 
factor  it  usually  is  possible  to 
distinguish  them  from  infantile 

paralysis,  which  is  flaccid.    In  children  they  usually  occur  from  injury 

at  birth,  and  there  often  is  mental  impairment  (p.  608);  but  they  may 

follow  cortical  or  meningeal  lesions  occurring 

in  the  exanthemata.     In  adults  they  may 

follow  cranial  injuries,  apoplexy,  etc.     The 

paralysis  is  hemiplegic,  paraplegic,  diplegic, 

or  monoplegic,  according  to  the  site  of  the 

cerebral    lesion.     The    hemiplegic    form  is 

most  frequent,  the  paraplegic  next,  while 

the  monoplegic  or  diplegic  types  are  quite 

rare.     The  flexor  muscles  are  stronger  than 

the  extensors,  and   the  deformity  is  quite 

characteristic:   the   arm    is    adducted,  the 

elbow  flexed,   the    forearm   pronated,    the 

wrist  flexed  and  the  hand  clasped  tight;  the 

hip  is  flexed  and  adducted,  the  knee  slightly 

flexed,  and  the   foot  in   the    equino-varus 

position,  there  being  a  tendency  to  walk  on 

the  toes  (Fig.  640  and  641).     By  gradual 

steady  pressure  it  usually  is  possible  to  cor- 
rect these  contractures,  but  as  soon  as  pres- 
sure is  released  they  recur,  the  patient  having 

very  little  if  any  voluntary  control  of  the 

affected  limbs.    In  the  course  of  time  the 

deformity     becomes      permanent,     unless 

malposition    is    prevented    by    orthopedic 

means. 

Treatment.— The  treatment  consists  in  the  use  of  massage  and 

manipulation  to  prevent  the  contractures  from  becoming  permanent. 


• 

Fig.  640. — Infantile  spastic 
paraplegia,  age  three  years. 
Attitude  in  attempting  to 
walk.     Orthopaedic  Hospital. 


PARALYTIC  DEFORMITIES 


573 


Malposition  should  be  prevented  by  splints  or  braces.  Tenotomy 
will  improve  position  temporarily,  but  relapses  are  common.  A  longer 
intermission  before  relapse,  and  better  prospects  of  permanent  func- 
tional improvement  are  offered  by  Stoft'el's  operation  (1912)  of  multiple 
peripheral  neurectomy:  the  nerve  supply  to  the  spastic  muscles  is 
damaged,  one-fifth,  one-fourth,  one-third,  or  more,  by  excision  of 
motor  branches  in  the  limbs;  this  secures  better  balance  of  power  be- 
tween the  spastic  and  the  weaker  antagonistic  muscles  (Figs.  641  and 
642).  Forster  (1908)  has  practised  intradural  division  of  the  sensory 
nerve  roots  (Rhizotomy)  supplying  the  affected  extremity,  but  the 
operation  is  dangerous  and  the  results  very  uncertain.  Xo  treatment 
is  of  much  value  in  cases  of  athetosis. 


Fig.    641.  —  Spastic   hemiplegia.     See 
Fig.  642.     Episcopal  Hospital. 


Fig.  642. — Same  patient  after  operation 
by  multiple  neurectomy.  Episcopal  Hos- 
pital. 


LATERAL  CURVATURE  OF  THE  SPINE. 

Lateral  Curvature  of  the  Spine,  or  Scoliosis,  is  an  affection  of  child- 
hood. It  is  convenient  to  distinguish  between  functional  or  postural 
lateral  curvature  and  true  organic  or  structural  scoliosis.  The  former 
is  due  simply  to  malposition,  and  there  is  a  general  (single)  curvature 


574  ORTHOPEDIC  SURGERY 

of  the  spinal  column,  usually  convex  to  the  left.  Round  shoulders 
often  coexist.  If  neglected,  these  children  may  develop  true  structural 
scoliosis,  as  the  bones  still  are  soft  and  their  shape  is  readily  altered 
by  long  continued  unequal  pressure.  The  diagnosis  of  postural 
lateral  curvature  is  easily  made  by  dropping  a  plumb-line  from  the 
vertebra  prominens,  and  noting  the  deviation  of  the  spinous  processes. 
The  child  may  be  brought  for  examination  on  account  of  stooping, 
round  shoulders,  or  general  relaxation  of  the  joints.  Proper  gymnas- 
tics, attention  to  hygiene,  manner  of  supporting  the  clothing,  etc., 
usually  effect  a  cure  in  from  one  to  two  years.  The  clothing  should 
not  be  supported  by  the  points  of  the  shoulders,  but  as  far  as  possible 
from  the  pelvis,  or  from  the  slope  of  the  neck;  any  ordinary  gym- 
nastic and  calisthenic  exercises  are  efficient;  over-study  and  tire  should 
be  avoided,  and  an  active  out-of-door  life  encouraged. 

In  organic  or  structural  scoliosis  there  is,  in  addition  to  lateral  devia- 
tion of  the  spinal  column  (Fig.  643),  also  rotation  of  the  bodies  of  the 
vertebra?,  the  transverse  processes  of  the  vertebrae  rotating  backward 
on  the  convexity  of  the  curve,  and  forward  on  its  concavity.  This 
rotation  is  best  appreciated  by  having  the  patient  bend  the  body 
horizontally  from  the  hips  (Fig.  644). 

Scoliosis  may  be  due  to  a  number  of  causes:  (1)  It  may  develop, 
as  already  mentioned,  as  a  sequel  of  postural  lateral  curvature;  this 
probably  is  the  most  frequent  cause.  Sometimes  it  is  convenient  to 
recognize  as  a  predisposing  cause,  in  cases  beginning  this  way,  a 
rachitic  or  other  dystrophic  softening  of  the  bones,  to  account  for  the 
rapidity  with  which  structural  changes  occur  in  the  spinal  column. 
(2)  Congenital  anomalies  of  the  spine  (studied  at  length  by  Mouchet 
and  Rouget  in  1910);  there  may  be  a  supernumerary  wedge-shaped 
vertebra;  or  a  portion  of  one  or  more  vertebras,  with  or  without  their 
attached  ribs,  may  be  absent.  The  deformity  in  these  cases  is  recog- 
nized in  early  infancy,  and  the  bony  lesion  usually  can  be  detected 
in  a  skiagraph.  (3)  Infantile  jxiralysis  or  other  muscular  lesion, 
allowing  unopposed  contraction  of  the  muscles  on  the  unaffected  side 
(Fig.  645),  is  a  more  frequent  cause  than  formerly  recognized.  (4) 
Empyema,  causing  collapse  of  the  thorax  on  the  affected  side,  is  a  fre- 
quent cause  (Fig.  847).  (5)  Torticollis,  and  other  deformities  of  neigh- 
boring parts,  such  as  ankylosis  of  the  hip  in  bad  position,  causing  tilting 
of  the  pelvis,  should  also  be  remembered  as  occasional  causes  of  this 
deformity. 

In  most  cases,  as  already  mentioned,  the  deformity  arises  from 
faulty  attitudes  in  sitting,  standing,  sleeping,  etc.  It  develops  most 
frequently  between  six  and  ten  years  of  age,  and  occurs  in  girls  in  over 
75  per  cent,  of  cases.  The  child  carries  heavy  books  or  a  heavy  baby 
habitually  on  one  arm;  sits  at  school  or  at  home  at  a  desk  or  table 
disproportionately  high,  requiring  habitual  undue  elevation  of  the 
right  shoulder;  one  leg  may  be  a  trifle  shorter  than  the  other,  or  the 
patient  may  sit  on  a  cushion  higher  on  one  side  than  on  the  other, 
inducing  obliquity  of  the  pelvis — in  short,  from  causes,  which  often 


LATERAL  CURVATURE  OF  THE  SPINE 


575 


cannot  be  defined ,  the  patient  is  brought  to  the  surgeon  (unfortunately 
seldom  until  the  deformity  has  existed  for  some  years)  complaining 
of  asymmetry,  with  projection  of  one  shoulder  and  one  hip,  usually 
the  right.  Such  patients  should  be  examined  with  the  back  bare  from 
neck  to  pelvis,  and  without  shoes  on  their  feet.  Even  if  no  asym- 
metry is  evident  at  a  glance,  it  is  extremely  likely  that  after  standing 
a  few  minutes  the  slouching  attitude  will  come  on,  and  reveal  the 
deformity.    In  the  immense  majority  of  cases  there  is  a  curve  convex 


Fig.  643. — Scoliosis,  in  a  girl  of  sixteen 
years;  left  shoulder  droops,  right  thorax 
(convex  curve)  is  prominent.  (See  Fig. 
644.)     Orthopaedic  Hospital. 


Fig.  644.— Patient  in  Fig.  643,  stoop- 
ing to  show  posterior  rotation  at  the  side 
of  the  convexity  of  the  curve.  Ortho- 
p'cedic  Hospital. 


to  the  right  in  the  thoracic  region,  which  compensates  a  curve  convex 
to  the  left  in  the  lumbar  region,  the  latter  being  regarded  as  the 
primary  curve.  (If  the  case  is  one  of  postural  scoliosis  only,  there 
seldom  is  more  than  one  curve,  which  usually  is  convex  to  the  left; 
placing  a  lift  under  the  left  foot  usually  causes  the  curve  to  disappear.) 
The  line  of  the  waist  is  more  cut  in  on  the  left  side,  a  distinct  fold 
often  existing  (Fig.  643) ;  and  when  the  patient  stoops  forward  at  the 
hips  the  right  thorax  becomes  prominent,  the  left  loin  projects,  and 
the  right  loin  falls  away  (Fig.  644).  In  extreme  cases  the  anterior 
surface  of  the  thorax  is  deformed  also,  the  left  lower  ribs  becoming 
very  prominent,  and  the  apex  of  the  right  lung  being  markedly  com- 


57(> 


ORTHOPEDIC  SURGERY 


pressed ;  sometimes 
the  left.     Valvular 


the  liver  is  proptosed,  and  the  heart  displaeed  to 
incompetency  is  frequent   in  cases  of  great  de- 
formity.    Besides  the  deformity,  the 
patient  complains  of  tiring  easily,  of 
weakness,  or  of  marked  disability. 

Diagnosis. — In  cases  of  very  slight 
degree  it  is  difficult  sometimes  to  be 
certain  that  the  affection  is  scoliosis 
and  not  incipient  tuberculosis  of  the 
spine.  In  the  latter  condition  there 
may  be  lateral  deviation  of  the  spine 
without  any  kyphosis;  but  the  lateral 
deviation  is  more  abrupt  than  the 
gentle  curve  of  scoliosis  (Fig.  715); 
there  is  painful  rigidity  of  the  spine  as 
detected  by  flexion,  hyperextension, 
and  lateral  bending;  there  usually  is 
tenderness  localized  to  the  seat  of 
disease;  there  may  be  constant,  slight, 
evening  rise  of  temperature;  and  the 
tuberculin  test  probably  will  be  posi- 
tive. A  skiagraph  may  reveal  a 
tuberculous  lesion;  but  in  cases  of 
scoliosis,  except  those  easily  recog- 
nized as  such  clinically,  will  show  no 
bony  change.  If  the  slightest  doubt  as 
to  the  nature  of  the  trouble  persists, 
treatment  for  Pott's  disease  (p.  659) 
should  be  instituted  until  its  absence 
is  proved. 

Treatment. — The  mildest  grades  of 
rotatory  scoliosis  may  be  overcome 
by  correction  of  habitual  malposi- 
tion and  special  gymnastic  exercises 
under  the  supervision  of  a  competent  orthopedic  surgeon.  The 
patient  should  sleep  on  a  hard,  flat  bed,  without  a  pillow,  and 
either  supine  or  prone;  she  should  spend  at  least  one  hour  each 
day  lying  flat  on  her  back  on  a  hard  level  couch  or  on  the  floor;  and 
should  give  up  habits  of  writing,  reading,  sewing,  etc.,  which  require 
a  cramped  posture.  Where  pain  or  disability  is  marked,  recumbent 
treatment,  with  head  and  foot  extension,  as  for  Pott's  disease  should 
be  instituted.  The  exercises  prescribed  for  scoliosis  cannot  be 
detailed  here;  they  form  almost  a  sub-specialty  in  orthopedic  practice, 
and  are  of  a  highly  technical  nature.  They  should  be  taken  daily 
(at  least  three  times  weekly)  for  from  one  to  three  hours  for  a  period 
of  nine  months  up  to  one  or  two  years.  It  is  folly  to  expect  per- 
manent improvement1  sooner.  In  most  cases,  certainly  in  those  in 
which  noticeable  rotation  is  present,  the  patient  should  be  provided 


Fig.  <>4.">. — Incipient  scoliosis,  fol- 
lowing infantile  palsy  one  year  ago. 
Age  four  years.  Left  side  paralyzed. 
Orthopaedic  Hospital. 


LATERAL  CURVATURE  OF  THE  SPINE 


577 


with  some  form  of  spinal  support;  for  all  severe  grades  of  deformity 
this  is  more  important  than  gymnastics,  as  it  is  futile  to  expect  to 
correct  bony  deformity  by  muscular  exercise.  As  H.  Bigg  (1905), 
Lovett  and  Sever  (1911),  and  other  recent  writers,  point  out,  the 
deformity  should  be  treated  on  the  same  principles  that  guide  us  in 
treatment  of  other  bony  deformities,  such  as  bow-legs  and  club  feet. 
The  most  efficient  corrective  apparatus  is  a  gypsum  jacket,  applied 
according  to  the  method  of  Abbott  (1912)  with  the  patient  lying  supine 
on  a  canvas  sling,  attached  at  each  end  to  a  special  frame  (Fig.  646). 
This  sling  is  cut  on  the  bias  at  one  end,  so  that  when  one  side  of  the 
sling  is  pulled  taut  the  other  is  relaxed.     The  taut  side  of  the  sling 


Fig.  646. — The  Abbot  frame  in  use.     Episcopal  Hospital. 


is  placed  under  the  prominent  side  of  the  thorax,  and  the  patient's 
head  and  thighs  are  thoroughly  flexed.  Then  bands  are  attached  to 
the  sides  of  the  frame  to  assist  over-correction  of  the  deformity,  and 
the  plaster  of  Paris  is  applied  and  moulded  carefully  to  the  body, 
which  has  been  padded  with  saddler's  felt  until  approximately  sym- 
metrical in  form.  When  the  plaster  has  set,  large  windows  are  cut  over 
the  compressed  portions  of  the  thorax  (usually  over  the  left  scapula 
and  lower  ribs  posteriorly,  and  the  right  mammary  region  anteriorly), 
and  the  pads  over  these  compressed  portions  are  removed,  while 
increasing  pressure  is  brought  to  bear  on  the  prominent  portions  of 
the  thorax  by  inserting,  at  intervals  of  a  few  days,  broad  felt  pads 
37 


578 


ORTHOPEDIC  SURGERY 


between  the  thorax  and  jaeket  (Fig.  647).  The  same  jacket  may  be 
worn  for  a  period  of  from  two  to  three  months.  A  new  jacket  then 
is  applied  for  a  month  or  six  weeks  longer;  and  this  treatment  is  con- 
tinued until  over-correction  of  the  deformity  has  been  obtained.     This 

form  of  treatment  is  the  most  efficient 
yet  devised,  but  is  not  applicable  to 
cases  of  fixed  bony  deformity  in 
adults.  When  overcorrection  has 
been  secured  it  should  be  maintained 
for  a  number  of  weeks.  In  less 
severe  cases  removable  jackets  or 
spinal  braces  may  be  used,  con- 
structed to  act  on  the  same  prin- 
ciples as  above  described;  they  are 
useful  also  after  the  fixed  dressings 
have  been  discarded. 

STATIC  DISORDERS  OF  THE  LUM- 
BAR SPINE  AND  PELVIS. 

These  were  studied  in  1901  by 
Goldthwait,  and  are  frequent  causes 
of  neurasthenia,  backache,  and  gen- 
eral disability,  especially  in  women. 
After  childbirth,  or  during  conva- 
lescence from  some  wasting  disease, 
or  simply  from  malnutrition,  over- 
work, etc.,  the  tone  of  the  pelvic 
and  lumbar  muscles  is  lowered, 
and  undue  strain  is  thrown  on  the 
ligaments.  Similar  symptoms  may 
occur  after  prolonged  anesthesia, 
during  which  the  patient  has  lain 
on  her  back  without  support  to  the 
lumbar  spine;  some  cases  of  "lumbago"  are  due  to  similar  conditions; 
and  most  patients  with  wThat  has  long  been  called  "neurotic  spine" 
have  some  static  disturbance  with  ligamentous  strain  as  the  basis  of 
their  trouble. 

The  most  frequent  condition  is  a  loss  of  the  normal  lumbar  lordosis; 
occasionally,  however,  somewhat  similar  symptoms  follow  increase 
of  the  lordosis,  caused  by  wearing  very  high-heeled  shoes,  by  anky- 
losis of  the  hip  in  a  flexed  position,  etc.  Flatness  of  the  back  often 
is  associated  with  weak  or  pronated  feet  (p.  591),  and  is  relieved  by 
treatment  of  the  foot  condition. 

The  normal  lumbar  lordosis  disappears  at  first  merely  when  the 
patient  is  supine;  later  it  is  absent  also  in  the  erect  posture.  The 
sacro-iliac  joints  and  symphysis  pubis  may  become  relaxed,  and  pain 
may  be  referred  down  the  sciatic  nerves;  while  at  each  step  the  patient 


Fig.  647. — Plaster  of  Paris  jacket 
applied  according  to  Abbott's  method 
for  the  treatment  of  scoliosis  (curve 
convex  to  right  in  thoracic  region). 
Large  window  cut  over  the  hollow  re- 
gion; the  left  shoulder  held  high  and 
forward;  the  right  shoulder  forced 
down  and  backward ;  the  pelvis  rotated 
forward  toward  the  right.  Orthopaedic 
Hospital. 


DEFORMITIES  OF  THE  HEAD  AND  NECK 


579 


may  feel  discomfort  and  may  obtain  relief  only  by  lying  prone,  or 
supine  with  the  lumbar  spine  supported  by  a  pillow.  One  sacro-iliac 
joint  frequently  is  more  relaxed  than  the  other.  By  placing  one  hand 
over  the  joint  while  the  other  palpates  the  symphysis  pubis,  it  usually 
is  possible  to  detect  abnormal  mobility  as  the  patient  stands  first 
on  one  foot  then  on  the  other.  Or  with  the  patient  lying  prone, 
the  sacro-iliac  joints  may  be  made  to  move  by  hyperextending  the 
thighs.  Very  severe  cases,  usually  unilateral,  resemble  sciatica  (p. 
325),  and  frequently  have  an  acute  onset,  following  sudden  or  pro- 
longed strain  on  the  lumbar  or  pelvic  joints,  perhaps  followed  by 
exposure  to  weather. 

Treatment. — The  treatment  in  mild  cases  consists  in  massage  of 
the  lumbar  muscles,  with  gymnastic  exercises.  In  severe  cases  it  may 
be  necessary  to  put  the  patient  to 
bed  with  weight  extension  to  the 
lower  extremities;  in  some  imme- 
diate relief  is  secured  by  forcibly 
hyperextending  the  hip  and  sacro-iliac 
joints  under  general  anesthesia,  and 
applying  a  gypsum  jacket  to  main- 
tain lordosis.  Some  form  of  spinal 
and  pelvic  support  must  be  provided 
for  weeks  or  months  during  conva- 
lescence. For  sacro-iliac  relaxation 
the  application  of  a  firm  pelvic  belt 
between  trochanters  and  iliac  crests 
often  is  all  that  is  required  (Fig.  648). 
Where  the  lumbar  spine  also  is  in- 
volved, it  will  be  necessary  to  support 
this  also,  maintaining  it  in  hyperex- 
tension. 

Spondylolisthesis  is  the  term  given 
to  subluxation  of  the  last  lumbar 
vertebra  forward  on  the  sacrum; 
occasionally  the  fourth  lumbar  verte- 
bra is  displaced  forward  on  the  fifth. 

The  affection  is  commonest  in  young  adult  females,  but  occurs  also 
in  growing  girls  and  in  youths  and  young  men.  There  is  a  depres- 
sion above  the  sacrum,  over  the  last  lumbar  vertebra,  and  sometimes 
a  prominence  can  be  felt  above  the  sacral  eminence  by  a  finger  in 
the  rectum  or  vagina.  The  symptoms  and  treatment  are  much 
the  same  as  for  static  strains  of  the  lumbar  spine,  of  which,  indeed, 
spondylolisthesis  may  be  considered  the  terminal  stage. 


Fig.  648.- 
ation. 


-Belt  for  sacro-iliac  relax- 
Orthopsedic  Hospital. 


DEFORMITIES  OF  THE  HEAD  AND  NECK 

Torticollis,  Caput  Obstipum,  or   Wry-neck,  sometimes  is  due  to 
injury  at  birth,  rupturing  some  of  the  fibers  of  the  sternomastoid  or 


580 


ORTHOPEDIC  SURGERY 


Fig.  649. 


-Torticollis  from  cervical  adenitis. 
Children's  Hospital. 


other  cervical  muscle.  It  is  uncertain  whether  the  cases  of  hematoma 
of  the  sterno-masioid  muscle  sometimes  seen  in  infants  are  a  result  of 
the  rupture  of  the  muscle  because  it  was  congenitally  short,  or  are 
themselves  the  cause  of  wry-neck  by  causing  subsequent  cicatricial 

contracture  of  the  muscle.  Often 
the  deformity  is  not  noticed  until 
the  child  is  several  months  old, 
and  then  it  is  difficult  to  be 
certain  whether  the  affection  is 
congenital  or  acquired.  As  a 
rule,  the  congenital  affection  is 
painless,  while  the  acquired  form 
has  a  more  or  less  acute  onset. 
Torticollis  may  be  symptomatic 
of  certain  other  diseases,  as 
astigmatism,  or  cervical  Pott's 
disease  (p.  649),  fracture-dislo- 
cation of  the  cervical  spine,  cer- 
vical rib,  cervical  adenitis  (Fig. 
049),  "rheumatic  stiff  neck," 
toothache,  ear-ache,  tonsillitis, 
or  other  affection  which  may 
irritate  the  spinal  accessory  or 
upper  cervical  nerves,  causing 
spasticity  of  the  muscles  concerned  in  the  production  of  the  deform- 
ity. These  are  especially  the  sternomastoid,  the  trapezius,  and  the 
scalenus  anticus,  especially  the  sternomastoid. 

Symptoms. — The  head  is  rotated  to  the  opposite  side,  the  chin  point- 
ing to  the  unaffected  shoulder,  while  the  ear  approaches  the  shoulder 
of  the  affected  side  (Fig.  050).  If  the  deformity  continues  long  uncor- 
rected, it  may  lead  to  facial  asymmetry,  scoliosis,  or  other  secondary 
deformities  which  cannot  be  remedied. 

Treatment. — The  surgeon  should  first  ascertain  that  the  deformity 
is  not  of  the  symptomatic  variety;  if  it  is,  removal  or  proper  treat- 
ment of  the  cause  of  irritation  usually  will  cause  the  wry-neck  to 
disappear.  If  no  cause  other  than  a  shortening  of  the  muscles  can  be 
found,  attempts  may  be  made  by  massage,  gymnastics,  or  apparatus 
to  overcome  the  deformity.  If  these  fail,  as  in  most  cases  they  do, 
the  surgeon  may  resort  to  division  of  the  contracted  structures.  In 
cases  of  short  duration  this  usually  is  quite  efficient,  but  in  many 
patients  the  most  that  can  be  expected  is  a  lessening  of  deformity. 
It  is  better  to  divide  all  resisting  structures  by  open  section  than  to 
attempt  a  subcutaneous  operation;  very  dense  cicatricial  bands,  which 
may  exist  in  the  cervical  fascia,  should  be  excised,  and  the  muscles 
divided  transversely  and  left  unsutured.  The  head  is  then  dressed  in 
an  over-corrected  position,  maintained  by  a  gypsum  case  (Fig.  651). 
Spasmodic  Torticollis,  a  form  of  Tic  Convnlsif.  is  an  affection  of 
obscure  origin,  consisting  essentially  in  sudden  tonic   involuntary, 


DEFORMITIES  OF  THE  HEAD  AND  NECK 


581 


and  usually  painful  contraction  of  the  neck  muscles,  momentarily 
turning  the  head  into  a  wry-neck  position  (Fig.  653.)  The  extent 
of  the  spasm,  and  the  number  of  muscles  involved,  varies  greatly. 


Fig.  650. — Congenital  torticollis  in 
a  boy  aged  ten  years.  Episcopal 
Hospital. 


Fig.  651. — Patient  shown  in  Fig.  650, 
in  plaster  case  after  open  tenotomy  of  the 
right  sternomastoid.     See  Fig.  652. 


The  disease  usually  begins  insidiously,  in  young  adult  life,  but  pro- 
gresses without  intermission  until  almost  the  entire  body  may  be  in- 
volved; any  effort  to  move  or  speak,  and  especially  any  excitement, 


Fig.  652. — Same  patient  as  Figs.  650 
and  651,  nine  months  after  operation. 


Fig.  653. — Spasmodic  torticollis. 
Orthopaedic  Hospital. 


brings  on  a  spasm,  and  the  patient  may  curl  up  in  a  knot,  as  it  were, 
on  the  side  affected,  being  absolutely  helpless  and  unable  to  straighten 
himself   out.    Many  surgical    measures   have  been   tried,   but  none 


582 


ORTHOPEDIC  SURGERY 


have  had  permanent  good  effect;  but  as  the  same  can  be  said  for 
medical  measures,  the  temporary  relief  which  follows  operation  should 
not  be  despised.  J  )ivision  of  the  nerves  supplying  the  cervical  muscles 
most  affected  is  the  operation  usually  done,  especially  division  of  the 
spinal  accessory  or  upper  cervical  nerves  (Keen,  1891). 

Cervical  Ribs. — On  one  or  both  sides  of  the  neck  a  rudimentary 
rib  may  be  formed,  usually  attached  to  the  seventh  cervical  vertebra, 
but  occasionally  to  the  sixth.  The  affection  is  said  to  be  bilateral  in 
75  per  cent,  of  cases,  and  occurs  in  females  three  times  as  often  as  in 
males.  If  the  rib  is  Aery  short,  no  symptoms  may  be  produced,  but 
usually  it  is  long  enough  to  reach  to  the  subclavian  artery,  which 
passes  over  the  rib,  and  may  be  compressed,  causing  symptoms  of 


Fig.  654. — Cervical  rib  (left);  age  eighteen  years.    Numbness,  tingling,  etc.,  for  four 
months.     (Dr.  W.  J.  Taylor's  case.)     Orthopaedic  Hospital. 

numbness,  tingling,  etc.,  in  the  extremity  affected.  Pressure  on  the 
brachial  plexus,  cervical  sympathetic  or  pneumogastric  nerves  may 
also  occur.  Usually  no  trouble  is  experienced  until  adult  life  (Fig. 
654).  In  most  cases  the  rib  is  palpable  in  the  neck;  and  the  abnormal 
position  of  the  artery,  as  well  as  changes  in  the  radial  pulse,  may 
simulate  aneurysm.  Rest  for  a  few  weeks,  with  elevation  of  the  arm, 
usually  causes  subsidence  of  acute  symptoms.  When  these  recur, 
and  are  disabling,  excision  of  the  abnormal  rib  should  be  done.  The 
operation  may  be  very  difficult,  from  the  altered  relations  of  blood- 
vessels, nerves,  and  muscles,  and  from  the  proximity  of  the  pleura. 
Complete  recovery  is  the  rule,  even  if  temporary  paralysis  occurs 
from  careless  handling  of  the  nerves. 


ACQUIRED  DEFORMITIES  OF  THE   UPPER  EXTREMITY     583 

ACQUIRED  DEFORMITIES   OF  THE  UPPER  EXTREMITY. 

Cubitus  Valgus,  or  increase  of  the  normal  "carrying  angle"  of 
the  upper  extremity,  sometimes  follows  rachitis,  but  most  often  is 
the  result  of  a  fracture  of  the  lower  end  of  the  humerus.  It  is  less 
frequent  and  less  disabling  than  cubitus  varus,  which  almost  always 
is  due  to  fracture,  especially  supracondylar  fractures  of  the  humerus. 
Either  deformity  may  be  treated  by  supracondylar  osteotomy  of  the 
humerus.  Some  surgeons  prefer  to  dress  the  arm  in  full  extension 
after  the  operation:  if  this  is  done,  for  valgus  deformity  the  forearm 
should  be  kept  in  supination,  which  relaxes  the  muscles  passing  from 
the  external  supracondylar  ridge;  while  for  varus  the  forearm  is 
dressed  in  full  pronation,  making  these  muscles  tense,  and,  there- 
fore, restoring  the  carrying  angle.  If  the  elbow  is  dressed  in 
hyperflexion,  as  in  a  recent  supracondylar  fracture,  the  precautions 
mentioned  at  page  383  against  varus  and  valgus  deformities  should 
be  observed. 

Ischemic  Contracture  (Stromeyer,  1838;  Volkmann,  1869)  is  due  to 
muscle  and  nerve  degenerations  following  ischemia  caused  by  pressure 
of  splints  or  bandages  applied  for  a  fracture  of  the  elbow  or  forearm. 
Very  rarely  it  has  followed  injury  in  which  no  splint  or  dressing  of 
any  kind  had  been  used.  It  has  been  reported  as  affecting  the  lower 
extremity  also.  Bardenheuer  (1911)  in  an  elaborate  study  of  the 
question,  concluded  that  the  degenerative  changes  were  due  to 
venous  stasis,  the  muscle  cells  being  poisoned  by  metabolic  products 
in  the  blood,  and  that  the  primary  cause  is  not  an  anemia  of  the  parts. 
Nerve  involvement  in  cases  of  ischemic  contracture  was  empha- 
sized by  J.  J.  Thomas  (1909).  The  hand  swells  and  becomes  cyanosed, 
and  the  parts  are  extremely  painful;  but  the  constriction  is  not  suffi- 
cient to  cause  gangrene.  After  a  few  days  the  pain  ceases,  and  swelling 
may  subside.  The  damage  is  done  within  a  few  hours,  and  cannot  be 
repaired  merely  by  removal  of  the  splints;  it  is  far  better  to  be  sure 
in  the  first  place  that  the  dressing  used  does  not  interfere  with  the 
circulation.  Usually  the  condition  develops  in  what  appears  an 
insidious  manner  only  because  the  surgeon  is  not  on  the  lookout  for 
it;  if  interference  with  the  circulation  persists  for  several  hours  there 
is  already  nerve  and  muscle  degeneration,  and  if  the  surgeon  was  suf- 
ficiently attentive  he  would  discover  it  at  the  next  dressing,  and  not 
be  surprised  when  subsequent  deformity  develops. 

The  deformity  is  quite  characteristic,  resembling  that  of  ulnar 
paralysis;  nor  is  this  resemblance  surprising  since  the  ulnar  nerve 
often  is  involved  (Fig.  655).  But  even  if  the  symptoms  of  neu- 
ritis are  present,  and  they  are  not  in  all  cases,  there  are  also 
symptoms  of  fibrous  degeneration  of  the  muscles  on  the  flexor  side 
of  the  forearm.  The  joints  are  not  affected,  motion  being  limited 
merely  by  muscular  contracture:  thus,  when  the  wrist  is  fully  flexed, 
extension  of  the  fingers  becomes  possible  (Fig.  656) ;  but  efforts  to 
straighten  the  wrist  at  once  cause  flexion  of  the  fingers  (Fig.  655). 


;,.s  i 


ORTHOPEDIC  SURGERY 


Frequently  there  are  pressure  sores  in  the  skin,  and  the  resulting 
cicatrices  aid  in  fixing  muscles,  tendons,  and  nerves,  in  one  almost 
inextricable  mass  of  adhesions. 

Treatment. — Very  little  can  be  done  until  the  ulcers  have  healed, 
except  to  prevent  further  deformity.  No  remedial  treatment  should 
be  undertaken  until  acute  symptoms  have  subsided.    Then  trial  may 


Fig.  655  Fin.  656 

Figs.  655  and   656. — Volkmann's  contracture  seven  weeks  after  greenstick  fracture  of 
radius  and  ulna  with  compression  of  median  and  ulnar  nerves.     (See  Figs.  657  and  658) . 

be  made  of  massage  and  passive  motion;  but  usually  very  slight  if 
any  improvement  is  secured.  R.  Jones  (1908)  applies  a  malleable 
metal  splint  to  each  ringer  up  to  the  carpal  joints,  first  with  the  wrist 
in  full  flexion,  a  position  which  usually  permits  nearly  full  extension  of 
the  fingers  (Fig.  656) ;  the  wrist  flexion  is  gradually  diminished  and  the 
finger  extension  progressively  increased  by  changing  the  angle  of  the 


Fig.  657  Fig.  658 

Figs.  657  and  658. — Eight  weeks  after  operation  (lengthening  of  all  superficial  and 
deep  flexors,  and  neurolysis  of  median  and  ulnar  nerves).  Patient  was  able  to  play 
the  piano  just  as  well  as  before  injury.     Episcopal  Hospital. 

finger  splints;  and  in  the  course  of  several  months  the  contracted  tissues 
may  be  sufficiently  relaxed  to  permit  fair  function.  In  most  cases, 
however,  especially  in  those  complicated  by  nerve  changes,  operation 
is  required.  This  consists  in  a  free  dissection  of  the  muscles,  tendons, 
and  nerves;  in  muscle  and  tendon  lengthening  (Anderson,  1889; 
Littlewood  and  Page,  1898),  and  in  preventing,  so  far  as  possible, 
formation  of  new  adhesions,  by  interposing  flaps  of  fat  (free  trans- 


ACQUIRED  DEFORMITIES  OF  THE   UPPER  EXTREMITY     585 

plants  if  necessary,  p.  246)  between  the  various  structures  (Figs.  657 
and  658). 

Binet  (1910)  studied  141  cases  of  Volkmann's  contracture,  and 
prefers  to  treat  them  by  resection  of  the  radius  and  ulna,  shortening 
the  forearm  until  the  tendons  become  relaxed  sufficiently  to  straighten 
the  fingers  (Colzi,  1892;  Henle,  1896;  Froelich,  1909);  but  while  good 
results  have  followed  this  method,  it  is  better  in  every  case  to  make 
sure  that  the  nerves  are  freed  from  adhesions. 

Spontaneous  Subluxation  of  the  Wrist  or  Manus  Valga  (Made- 
lung's  Disease,  1878). — The  symptoms  of  this  affection  usually  are 
manifested  about  the  age  of  puberty;  it  affects  particularly  females; 
and  involves  both  wrists  in  about  50  per  cent,  of  cases.  Especially 
characteristic  in  radiograms  is  the  widening  of  the  interosseous  space, 
due  to  incurvation  of  the  lower  end  of  the  radius,  the  normal  flexor  con- 
cavity of  which  becomes  much  exaggerated.  The  hand  thus  is  carried 
forward  with  the  articular  surface  of  the  radius,  while  the  ulna,  which 
is  not  displaced  forward,  appears  to  be  unduly  prominent  (Fig.  659). 
Siegrist  (1908)  collected  62  cases,  only  10  of  which  were  in  males. 


Fig.  659. — Madelung's  disease;  male,  aged  twenty-four  years.     Began  about 
eight  years  of  age.     Episcopal  Hospital. 

The  affection  has  been  attributed  by  some  to  adolescent  rachitis; 
others  are  satisfied  to  describe  it  as  an  obscure  form  of  osteitis  affecting 
the  radius.  In  the  last  few  years  there  has  been  a  tendency  to  regard 
it  as  a  congenital  deformity,  to  which  attention  is  first  directed  at 
an  age  when  local  over-exertion  and  constitutional  malnutrition  exert 
their  influence.  In  addition  to  the  deformity  there  often  is  discom- 
fort from  pain  or  ache,  and  some  disability  from  loss  of  extension  and 
circumduction  at  the  wrist.  Usually  these  are  relieved  by  splinting, 
or  orthopedic  apparatus,  with  constitutional  treatment.  In  severe 
cases  osteotomy  of  the  radius  may  be  done  to  overcome  deformity. 

Contracture  of  the  Palmar  Fascia  (Dupuytren's  Contracture,  1832). 
— This  affection  occurs  in  adults  past  middle  life,  particularly  men, 
and  in  some  cases  seems  to  be  caused  by  slight  recurring  trauma  from 
the  handles  of  tools,  canes,  etc.  In  about  half  the  cases  both  hands 
are  affected,  usually  the  right  before  the  left.  The  fascia  is  the  seat 
of  chronic   inflammatory  changes,1   with   secondary  contracture;   it 

1  These  are  classed  by  the  Lyons  surgeons  as  a  form  of  inflammatory  tubercu- 
losis. 


580 


ORTHOPEDIC  SURGERY 


becomes  densely  adherent  to  the  skin;  and  the  resulting  deformity 
may  totally  disable  the  patient.  The  thumb  and  index  finger  are  the 
last  to  succumb. 

Temporary  relief  may  be  secured  by  tenotomy  of  the  tense  fascial 
bands,  introducing  the  tenotome  between  the  skin  and  fascia  and  cut- 
ting downward  (Adams,  1879);  the  fingers  should  be  dressed  on  a  splint 
in  full  extension  for  two  weeks,  and  this  splint  should  be  worn  at 
night  for  two  weeks  longer.  But  recurrence  of  the  deformity  is  usual. 
Excision  of  the  contracted  bands  was  introduced  by  Kocher  (1887), 
and  Keen  (1906)  reflected  a  skin  flap,  including  the  adherent  fascia, 
which  was  then  dissected  off  the  skin  before  this  was  replaced.  Gill 
(1919)  reports  success  from  free  fat  transplants,  following  excision 
of  the  fascia  through  the  distal  palmar  crease.  The  fascia  is  so 
densely  adherent  that  some  sloughing  is  liable  to  occur.  Lexer  and 
others  have  excised  skin  and  fascia  in  one  piece,  and  filled  the  gap  by 
a  flap  of  skin  transplanted  from  elsewhere. 


Fig.  660. 


-Dupuytren's  contracture  of  the  palmar  fascia;  early  stage, 
sixty-six  years.     Episcopal  Hospital. 


Age 


Trigger  Finger. — Trigger  finger  is  a  condition  in  which  there  is  some 
obstacle  to  voluntary  flexion  or  extension  of  the  finger,  which  flies 
"shut"  or  "open"  when  passively  moved  past  the  position  where 
it  catches.  The  usual  obstacle  is  a  fusiform  thickening  of  one  of  the 
flexor  tendons,  and  the  hitch  occurs  where  the  deep  tendon  perforates 
the  superficial.  If  rest  on  a  splint  for  some  weeks,  followed  by  massage, 
proves  ineffectual  in  relieving  the  condition,  the  tendon  sheath  may 
be  opened  and  the  thickening  of  the  tendon  excised.  Cotton  (1911) 
referred  to  160  cases,  in  about  40  of  which  operation  was  done. 


ACQUIRED  DEFORMITIES  OF  THE  LOWER  EXTREMITY. 

Coxa  Vara. — Normally  the  neck  of  the  femur  forms  an  angle  of 
about  135  degrees  with  the  shaft;  when  this  angle  is  notably  decreased 
(115  degrees  or  less)  coxa  vara  is  said  to  exist.     The  deformity  con- 


ACQUIRED  DEFORMITIES  OF  THE  LOWER  EXTREMITY     587 

sists  in  elevation  of  the  great  trochanter  and  a  relative  depression 
of  the  femoral  head,  which,  however,  retains  its  position  within  the 
acetabulum.  Coxa  vara  may  result  from  trauma,  especially  epiphyseal 
separation  of  the  head  or  fracture  of  the  cervix  in  children;  from 
rachitic  softening  of  the  bones,  when  the  deformity  usually  is  bilateral 
(Fig.  661);  or  from  not  very  well  defined  causes,  chiefly  in  adolescents. 
(See  Rottenstein  and  Houzel,  1910;  Perrin,  1912.) 


Fig.  661. — Skiagraph  of  bilateral  coxa  vara  (rachitic).     Note  rachitic  pelvis- 
acetabula  pressed  together.     Orthopaedic  Hospital. 


Symptoms. — The  symptoms  are  those  of  the  underlying  or  preceding 
condition;  slight  limp,  limitation  of  abduction,  because  the  trochanter 
strikes  the  pelvis;  marked  prominence  of  the  trochanter  when  the 
thigh  is  flexed  (Fig.  662);  increased  range  of  adduction,  especially 
when  the  thigh  is  flexed;  elevation  of  the  trochanter  above  Nelaton's 
line;  and,  in  cases  due  to  trauma,  usually  external  rotation  of  the 
lower  extremity.  There  is  moderate  shortening,  but  seldom  much 
pain,  relief  being  sought  for  the  limp  and  deformity. 

Treatment. — In  many  cases  no  treatment  is  required;  in  some,  the 
addition  of  a  lift  to  the  heel  brings  relief  by  overcoming  shortening. 
In  cases  with  great  deformity  a  cuneiform  osteotomy  of  the  femur 
may  be  done,  as  advised  by  Whitman  (1901),  removing  a  wedge 
with  its  apex  at  the  lesser  trochanter;  or  simple  linear  osteotomy 
may  suffice.  The  thigh  is  dressed  in  extreme  abduction,  and  when 
consolidation  is  complete,  adduction  will  restore  approximately  the 
normal  relations  of  neck  and  shaft  (Figs.  663  and  664).  In  recent  cases 
of  impacted  fracture  of  the  head  or  neck  in  children  or  adolescents, 
the  deformity  may  be  overcome  by  forcible  abduction  under  an 
anesthetic. 


f,ss 


ORTHOPEDIC  SURGERY 


Legg's  or  Perthes's  Disease. — A  dystrophic  condition  of  the  hip- 
joint  exists,  known  as  Legg's  or  Perthes's  Disease  (osteochondritis 
deformans  juvenilis);  it  was  studied  by  Calve,  by  Legg  and  by  Perthes 
in  L910.  By  some  it  is  considered  traumatic  in  origin.  It  arises  in 
childhood,  the  patient  limping  but  making  little  complaint  of  pain. 
X-rays  show  irregularity  in  the  head  of  the  femur  and  in  the  neck 
near  the  cartilage.  In  time  the  head  becomes  flattened.  Tuberculosis 
must  be  excluded.  It  may  be  syphilitic.  Some  disability  may 
persist  in  adult  life  (Fig.  665).  Treatment  comprises  rest  during  the 
active  stage,  with  support  from  a  gypsum  case.     Prognosis  is  good. 


Fig.    663. — Whitman's    wedge-shaped    oste- 
otomy of  the  femur  for  coxa  vara. 


Fig.  662. — Coxa  vara  from  fracture 
of  cervix  femoris  as  infant.  Note 
prominence  of  great  trochanter  when 
thigh  is  flexed.     Episcopal  Hospital. 


Fig.  664.— Whitman's  operation  for  coxa 
vara.  Consolidation  has  occurred  in  the 
abducted  position. 


Coxa  Valga  (Fig.  666)  is  a  much  rarer  condition,  in  which  the  neck 
of  the  femur  makes  with  the  shaft  an  angle  of  more  than  135  degrees. 
The  trochanter  is  less  prominent  than  normally,  abduction  is  increased 
and  adduction  diminished.  There  usually  is  outward  rotation  of 
the  lower  extremity.  The  deformity  may  be  congenital  and  usually 
is  observed  in  limbs  which  never  have  borne  any  weight.  Efforts 
may  be  made  to  increase  the  adduction  by  manipulation  under  an 
anesthetic.  The  best  study  of  the  subject  is  by  Worms  and  Ham  ant 
(1915). 

Snapping  Hip  (die  schnellende  Hiifte,  la  Hanche  a  Ressort).  This 
affection   was  carefully  studied  by  L.  Heully  (1911),  wh     collected 


ACQUIRED  DEFORMITIES  OF  THE  LOWER  EXTREMITY     589 

57  cases.  He  proposed  the  term  "ressaut  fascio-glvteal,"  as  explain- 
ing what  he  believed  to  be  the  pathology  of  the  condition  which 
has  been  recognized  since  1859,  though  dispute  as  to  its  nature  has 
always  existed.  Perrin,  who  reported  the  first  case,  believed  it  to 
be  a  form  of  voluntary  luxation  of  the  hip;  but  the  study  of  Heully 
confirms  the  opinion  of  Morel-Lavallee,  Chassaignac,  and  others, 
that  it  is  due  to  sudden  slipping  of  the  fascia  lata  (altered  by  injury 
or  congenitally  deformed)  over  the  surface  of  the  great  trochanter. 
The  phenomenon  occurs  especially  during  flexion  and  internal  rota- 


Fig.  665. — Flat-headed  femur  in  a  lad  aged  eighteen  years,  following  multiple 
arthritis  at  age  of  five  years.     Episcopal  Hospital. 

tion  of  the  thigh,  but  in  some  cases  slight  movements  of  the  pelvis 
on  the  lower  extremity  are  sufficient  to  produce  it.  In  traumatic 
cases  the  lesion  is  separation  of  the  upper  part  of  the  tendon  of  the 
gluteus  maximus  from  its  insertion  in  the  linea  aspera,  and  the  snap 
occurs  involuntarily  and  is  painful;  while  in  congenital  cases  it  is 
not  painful  and  usually  is  under  voluntary  control,  possibly  being 
due  to  abnormally  low  insertion  of  the  gluteus  tendon  in  the  linea 
aspera  (Heully).  The  defect  may  be  repaired  by  suturing  the  tendon 
to  the  periosteum  of  the  great  trochanter  and  aponeurosis  of  the 
vastus  externus. 


590 


ORTHOPEDIC  SURGERY 


Anterior  Metatarsalgia. — T.  G.  Morton  in  1876  described  a  condition 
which  was  believed  by  him  to  be  due  to  pinching  of  a  nerve  between 
the  heads  of  the  fourth  and  fifth  metatarsal  bones  ("Morton's  toe"). 
A  sudden  unendurable  cramp  in  the  anterior  metatarsus  occurs  while 
the  patient  is  walking,  and  he  is  forced  to  remove  the  shoe  at  once, 
rub  and  manipulate  the  foot,  and  flex  and  extend  the  toes,  until  the 
pain  passes.  This  series  of  events  may  be  repeated  a  number  of 
times,  but  except  in  the  most  aggravated  cases  the  attacks  never 


Fig.  666. — Coxa  valga,  apparently  congenital,  in  a  girl  of  twelve  years.  Angle 
between  neck  and  shaft  is  165  degrees  on  the  right;  on  the  left  (normal)  it  is  130 
degrees.     Episcopal  Hospital. 

come  on  except  when  walking,  and  with  a  shoe  on  the  foot.  More 
recent  observations,  especially  by  Goldthwait  and  Whitman,  have 
shown  that  weakness  in  the  transverse  arch  of  the  foot  is  an  important 
factor,  and  may  cause  various  minor  symptoms  before  metatarsalgia 
develops.  Callosities  may  form  on  the  sole  over  the  heads  of  the 
metatarsals,  especially  the  second  and  third;  and  pain  may  be  caused 
by  lateral  compression  by  a  shoe  which  would  be  comfortable  if  the 
normal  convexity  of  the  arch  were  maintained.  Relief  usually  may 
be  obtained  by  wearing  broader  shoes,  and  by  applying  a  small  longi- 


ACQUIRED  DEFORMITIES  OF  THE  LOWER  EXTREMITY     591 

tudinal  pad  of  saddler's  felt  beneath  the  insole  with  its  anterior  rather 
abrupt  edge  just  back  of  the  heads  of  the  metatarsals,  thus  relieving 
them  from  strain;  or  a  similar  appliance  known  as  an  anterior  heel.  The 
patient  should  actively  exercise  the  toes  in  flexion,  and  may  benefit 
from  massage. 

Flat-foot  (Pes  Planus). — This  very  frequent  affection  is  an  evidence 
of  weakness  in  the  foot.  In  a  foot  that  is  merely  weak,  however, 
the  antero-posterior  arch  may  still  be  preserved,  but  a  tendency 
to  pronation  exists:  when  weight  is  put  on  the  foot  the  internal 
malleolus  descends  and  rotates  backward,  causing  a  relative  outward 
displacement  of  the  anterior  part  of  the  foot;  the  patient  walks  with 
the  toes  well  turned  out,  and  to  bring  the  two  feet  parallel  it  may  be 
necessary  to  rotate  both  entire  lower  extremities  inward,  so  that  the 
patella?  look  toward  each  other  rather  than  anteriorly.    In  truly  flat 


Fig.  667. — Flat  feet,  in  a  boy  of  eight 
years.  (See  Fig.  668.)  Orthopaedic  Hos- 
pital. 


Fig.  668.— Flat  feet  foot-prints. 
Same  patient  as  Fig.  667.  Ortho- 
paedic Hospital. 


feet  the  arch  is  depressed,  and  in  aggravated  cases  the  scaphoid  may 
rest  on  the  floor  (Fig.  667) .  The  affection  is  common  at  all  ages,  and 
may  be  very  disabling.  In  adolescents  painful  flat-foot  often  is  an 
early  evidence  of  tuberculosis  of  the  tarsus,  and  this  diagnosis  always 
should  be  carefully  considered.  In  young  children  the  foot  remains 
perfectly  flexible,  but  if  the  condition  persists  for  years  unrelieved, 
great  rigidity  may  develop;  and  in  adults  more  or  less  rigidity  is  the 
rule.  In  cases  where  rigidity  is  absent  much  may  be  done  by  proper 
exercises,  even  without  mechanical  support.  The  patient  should 
rise  on  to  the  toes  of  both  feet  simultaneously,  from  ten  to  twenty 
times,  morning  and  night;  he  should  then  attempt  to  supinate  his 
feet  the  same  number  of  times  by  flexing  his  toes  and  contracting 
the  tibialis  anticus  and  posticus  muscles;  and  flexion  exercises  of  the 
toes  with  the  feet  off  the  ground  also  should  be  prescribed.  Walking 
on  the  toes,  and  on  the  outer  side  of  the  soles  is  another  valuable 


592 


ORTHOPEDIC  SURGERY 


exercise.  In  most  cases,  however,  it  is  desirable  to  support  the  arch 
in  walking:  for  this  purpose  the  first  thing  is  to  secure  a  pair  of  strong 
shoes,  made  on  a  straight  or  nearly  straight  last,  with  broad  toes, 
low  heels  and  a  wide  shank;  the  shoes  should  be  "high"  shoes,  laced. 
Many  sole  plates  are  sold  in  the  stores  for  the  purpose,  but  as  they 
scarcely  ever  fit  the  foot  to  which  they  are  applied,  it  rarely  is  proper 
to  use  them.  If  a  sole  plate  is  to  be  used  it  should  be  made  for  the 
individual  patient,  moulded  on  a  cast  of  his  foot  taken  in  the  resting 
position.  An  easier  and  as  efficient  method,  I  believe,  is  to  have  a 
shoemaker  insert  a  steel  strip  in  the  shank  of  the  shoe,  and  then  to 
build  up  the  arch,  to  any  height  desired,  by  properly  cut  felt  pads 
placed  beneath  the  inner  sole.  The  height  of  this  pad  may  be  increased 
or  decreased  at  will.  In  very  rigid  feet,  benefit  is  derived  from  massage, 
passive  movements,  and  baking.  Sometimes  "Mobilisierung"  under 
an  anesthetic,  with  tenotomy  of  the  tendon  of  Achilles  or  of  the  pero- 
neal tendons,  may  be  necessary;  after  such  an  operation  the  foot 
is  dressed  in  plaster  of  Paris  in  the  varus  position  for  several  weeks, 
when  proper  apparatus  may  be  applied. 


Fig.  669. 


-Hammer  toe  in  a  man  of  twenty-six;  duration  since  childhood. 
Episcopal  Hospital. 


Hammer  Toe. — Hammer  toe  (Digitus  malleus)  is  a  deformity  of 
extension  at  the  metatarso-phalangeal  joint  and  flexion  at  the 
proximal  interphalangeal  joint  (Fig.  669).  It  is  commonest  in  the 
second  toe,  which,  being  the  longest,  suffers  most  from  short  and 
narrow  shoes.  The  condition  usually  begins  in  childhood.  A  corn 
forms  over  the  prominent  phalangeal  joint,  and  the  end  of  the  toe 
becomes  club-shaped.  If  massage,  application  of  adhesive  plaster 
strapping,  etc.,  do  not  relieve  symptoms,  tenotomy  of  the  contracted 
tendons  (extensor  and  flexor)  may  be  done;  the  head  of  the  metatarsal 
may  be  excised;  and  in  relapsed  cases  the  toe  may  be  amputated. 

Hallux  Valgus. — Hallux  valgus  is  a  deformity  in  which  the  great 
toe  is  abducted,  often  lying  on  the  top  of  or  under  the  other  toes. 
This  results'in  marked  prominence  of  the  first  metatarso-phalangeal 
joint;  and  over  this  a  bursa  is  formed  by  friction  of  the  shoe  (Figs. 


ACQUIRED  DEFORMITIES  OF  THE  LOWER  EXTREMITY     593 

670  and  671).  In  some  cases,  the  primary  cause  of  the  deformity  is 
adduction  of  the  first  metatarsal  bone,  which  may  be  a  congenital 
deformity.     If  proper  shoes  which  do  not  abduct  the  toes  fail  to  secure 


Fig.  670. — Hallux  valgus.  Same  pa- 
tient shown  in  Fig.  671.  Episcopal  Hos- 
pital. 


Fig.  671.— Hallux  valgus.  After 
operation.  (Sesamoid  bones  restored 
to  normal  site  beneath  metatarsal.) 


Fig.  672. — Exostoses  of  calcaneum  at  attachments  of  plantar  fascia  and  tendo  Achillis, 
in  a  patient  aged  forty-four  years.  Duration  of  symptoms,  over  two  months.  Also 
has  incipient  hypertrophic  arthritis  of  hip.  Orthopaedic  Hospital. 

38 


VII  ORTHOPEDIC  SURGERY 

relief,  excision  of  the  projecting  head  of  the  first  metatarsal  may  be 
done  (Fig.  671).  C.  II.  Mayo  (1908)  preserves  the  bursa  and  inserts 
it  between  the  bones. 

Painful  Heel. — Painful  heel  may  be  due  to  a  variety  of  causes. 
Trauma  may  cause  rupture  of  some  fibers  of  the  tendo  Achillis 
(Achillodynia),  or  produce  inflammation  in  the  retrocalcaneal  bursa 
(Achillobursitis,  p.  298),  or  in  a  bursa  sometimes  present  between  the 
Achilles  tendon  and  the  skin;  or  it  may  cause  strain  on  the  attach- 
ment of  the  plantar  fascia,  as  is  common  in  flat  feet.  Subsequently, 
exostoses  may  develop  at  these  points  of  strain.  Infections,  especially 
gonococcic,  and  some  forms  of  sub-pyemic  or  cryptogenous  infection 
(Fig.  G72)  may  cause  exostoses  to  form  on  the  calcaneum  or  other  tarsal 
bones;  or  similar  changes  maybe  an  evidence  of  hypertrophic  arthritis 
(p.  497). 

Treatment. — The  treatment  consists  in  care  of  the  underlying 
condition  (sprain,  flat-foot,  gonorrhea,  etc.);  local  rest  by  proper 
orthopedic  shoes,  etc.;  and,  in  cases  which  resist  conservative 
measures,  in  excision  of  the  exostoses. 


CHAPTER   XVII. 
SURGERY  OF  THE  HEAD. 


SURGICAL  AFFECTIONS  OF  THE  SCALP. 

Birth  Injuries. — During  parturition  that  portion  of  the  scalp 
which  protrudes  into  the  birth  canal  may  become  edematous  from 
pressure  on  surrounding  parts;  this  condition,  which  is  known  as 
ccq)ut  suecedanewn,  may  be  recognized  by  the  history  of  prolonged 
or  difficult  labor,  by  the  facts  that  it  is  present  at  birth,  that  the 
affected  area  pits  on  pressure  and  presents  no  signs  of  inflammation; 
while  it  may  be  distinguished  from  cephalhematoma  (see  below)  by 
the  fact  that  the  swelling  is  not  limited  to  the  outline  of  one  bone. 
The  swelling  disappears  in  a  few  hours  or  days,  and  usually  no  treat- 
ment is  necessary.  Cephalhe- 
matoma is  an  extravasation  of 
blood  beneath  the  pericra- 
nium; it  is  encountered  in 
about  one  labor  out  of  two 
hundred.  Usually  the  right 
parietal  is  the  bone  affected, 
and  it  is  probable  that  in 
many  cases  the  bone  itself  is 
directly  injured,  either  bent 
or  broken  (p.  608).  As  the 
pericranium  is  attached  at 
the  sutures,  the  hemorrhage 
never  passes  the  limits  of  the 
bone  affected;  generally  the 
condition  is  not  noticed  for  a 
day  or  two  after  birth,  and 
at  this  time  the  blood  at  the 
periphery  may  have  become 

clotted  or  organized,  so  that  the  scalp  presents  an  indurated  ring  with 
a  softened  or  fluctuating  center.  Occasionally  thin  plates  of  sub- 
periosteal bone  develop,  and  the  bone  crackles  on  palpation.  In 
most  cases  no  treatment  is  required,  but  if  no  evidence  of  absorption 
is  seen  after  two  weeks  the  fluid  may  be  evacuated  by  puncture; 
pressure  should  then  be  applied  to  prevent  re-accumulation.  Should 
infection  of  the  hematoma  occur,  from  the  deep  skin  cocci  or  through 
the  blood  stream,  it  should  be  drained  (Fig.  673). 

Contusions. — Contusions  of  the  scalp  are  frequent  at  all  ages.  If 
the  head  is  examined  immediately  after  the  injury,  the  impress  of  the 
vulnerating  body  may  be  detected;  but  swelling  occurs  very  quickly, 

(595) 


Fig.  673. — Suppurating  cephalhematoma  in 
an  infant  of  five  weeks.  Incised.  Death  in 
four  days.     Children's  Hospital. 


59G 


SURGERY  OF   THE  HEAD 


and  usually  the  only  signs  are  those  of  edema,  and  possibly  hematoma. 
The  blood  usually  is  extravasated  in  the  subcutaneous  tissues,  super- 
ficial to  the  aponeurosis  of  the  occipito-frontalis.  It  may  be  difficult 
to  distinguish  such  cases,  after  the  lapse  of  a  few  hours,  from  depressed 
fractures  of  the  skull  as  the  contusion  presents  a  soft  depressed  center, 
surrounded  by  an  indurated  area  due  to  inflammatory  reaction  and 
commencing  organization;  but  firm  pressure  in  the  center  detects 
solid  bone  at  the  same  level  as  the  surrounding  cranial  surfaces,  and 
there  is  no  irregular  outline  to  the  depressed  area,  such  as  is  commonly 
present  in  fracture;  moreover,  the  elevated  margin  moves  with  the 

scalp  upon  the  bone  beneath.  In  cases 
of  doubt  the  scalp  should  be  incised  and 
the  skull  inspected.  A  hematoma  beneath 
the  occipito-frontalis  is  widely  diffused, 
and  may  be  of  great  size.  In  most  cases 
hematomas  of  the  scalp  subside  under 
pressure  by  bandages,  application  of  cold, 
and  rest  in  bed;  if  no  diminution  in  size 
is  evident  after  ten  days,  or  if  infection 
occurs,  the  hematoma  should  be  incised, 
and  pressure  applied,  when  the  cavity  will 
heal  by  granulation. 

Wounds. — Wounds  of  the  scalp  may 
result  from  blunt  force,  as  well  as  from 
cutting  instruments,  as  the  scalp  is  very 
readily  split  on  the  underlying  bone. 
Bleeding  is  free,  as  the  bloodvessels  are 
unable  to  contract  and  retract,  being 
enmeshed  in  the  firm  fibrous  processes 
which  bind  the  skin  to  the  aponeurosis. 
This  also  renders  it  difficult  to  catch 
the  bleeding  points  in  hemostats,  or  to 
apply  ligatures;  the  surgeon  usually  de- 
pends on  sutures  to  arrest  the  bleeding. 
Temporary  control  of  hemorrhage  is  easily 
secured  by  pressure  on  the  margins  of  the  wound ;  and  during  an  oper- 
ation hemostasis  sometimes  may  be  secured  by  applying  an  Esmarch 
band  or  other  form  of  elastic  tourniquet  around  the  crown  of  the 
head.  Wounds  which  divide  the  occipito-frontalis  aponeurosis  trans- 
versely gape  much  more  than  longitudinal  wounds;  and  when  the 
loose  subaponeurotic  areolar  tissue  is  opened  there  is  much  greater 
danger  of  infection  arising,  especially  if  the  wound  is  closed  without 
drainage  (Fig.  674).  Owing  to  the  great  vascularity  of  the  parts 
large  portions  of  the  scalp  may  be  avulsed  and  yet  retain  their  vitality 
when  properly  cleansed  and  sutured  in  place.  When  the  skull  has 
been  denuded  of  its  pericranium  over  large  areas,  some  caries  is 
very  apt  to  occur,  but  if  the  soft  parts  are  promptly  replaced  no 
such  result  need  be  anticipated  unless  infection  is  present. 


Fig.  674. — Lacerated  wound  of 
the  scalp,  with  subaponeurotic 
cellulitis;  the  result  of  sealing 
the  wound  with  a  cotton  and 
collodion  dressing.  Forty-eight 
hours  after  injury  the  cellular 
infiltrate  had  gravitated  into  the 
temporal  region  where  it  was 
arrested  by  the  attachment  of 
the  temporal  fascia  to  the  zy- 
goma.    Episcopal  Hospital. 


SURGICAL  AFFECTIONS  OF  THE  SKULL 


597 


In  all  scalp  wounds  a  large  surrounding  area  should  be  shaved, 
all  foreign  bodies  removed  from  the  wound,  and  this  should  be  cleaned 
with  antiseptics.  Silkworm  gut  sutures 
should  be  used,  and  if  there  is  any  risk  of 
a  hematoma  forming,  or  if  the  subapon- 
eurotic space  has  been  opened,  the  wound 
should  be  drained  for  a  few  days. 

Tumors.  —  Tumors  of  the  scalp  apart 
from  sebaceous  cysts(  Fig.  2G3,  p.  296)  are 
not  very  frequent.  In  infancy  dermoid 
cysts  (Fig.  266,  p.  296)  sometimes  are 
seen;  these  usually  grow  in  the  region  of 
the  embryonal  clefts,  occurring  in  or  near 
the  orbit,  at  the  glabella,  or  over  one  of 
the  fontanelles;  usually  they  are  more  or 
less  immobile,  deep-seated,  and  are  not 
attached  to  the  epiderm,  being  thus  easily 
distinguished  from  ordinary  wens.  If  not 
removed  in  infancy,  the  underlying  bone 

may  be  absorbed  from  pressure,  and  the  growth  may  become  adherent 
to  the  dura  mater,  making  its  removal  more  difficult.  Papillomatous 
growths  of  the  scalp  should  be  eradicated  by  cauterization,  or  excised, 
as  they  are  prone  to  undergo  epitheliomatous  change.  Epithelioma 
often  develops  in  scars  from  burns,  syphilitic  ulcers,  etc.  Sarcoma 
may  arise  in  the  scalp  or  the  cranial  bones,  and  the  latter  are  rapidly 
invaded  by  tumors  which  at  first  were  superficial  (Fig.  675) .  Usually 
no  operation  is  of  any  use. 


Fig.  675. — Sarcoma  of  scalp. 
Death  a  few  months  after 
photograph  was  made.  (Dr. 
W.  L.  Rodman's  case.)  Pres- 
byterian Hospital. 


SURGICAL  AFFECTIONS  OF  THE  SKULL 

Congenital  Malformations. — Cephalocele. — Occasionally  at  or  soon 
after  birth  a  fluctuating  tumor  of  the  head  is  found  which 
evidently  protrudes  through  the  skull  and  is  composed  of  cranial 
contents.  The  growth  occurs  oftenest  in  the  region  of  the  posterior 
fontanelle  (occipital  cephalocele),  though  it  may  also  protrude  at  the 
root  of  the  nose  (sincipital  cephalocele),  or  very  rarely  at  the  anterior 
fontanelle  or  through  one  of  the  cranial  sutures.  The  tumor  usually 
is  wholly  or  partly  reducible  by  pressure,  which  if  excessive  may 
cause  symptoms  of  cerebral  compression  (p.  617) ;  and  it  becomes  more 
prominent  and  tense  when  the  child  cries.  It  frequently  is  possible 
to  detect  the  defect  in  the  cranium  through  which  the  protrusion 
occurs.  If  the  protrusion  is  composed  solely  of  the  meninges,  with 
subarachnoid  fluid,  it  is  called  a  meningocele;  an  encephalocele  contains 
also  some  brain  substance;  while  a  protrusion  formed  by  a  diver- 
ticulum of  one  of  the  ventricles  is  called  a  hydrencephalocele  or  an 
encephalocystocele.  It  formerly  was  believed  that  the  most  frequent 
form  was  the  meningocele;  but,  though  the  protrusion  resembles 
this  macroscopically,  histological  study  has  proved  that  most  cases 


598  SURGERY  OF  THE  HEAD 

really  are  encephalocystoceles,  as  the  cavity  of  the  cyst  is  lined  by 
ependymal  cells,  which  are  directly  continuous  with  those  of  the 
ventricles  of  the  brain,  while  the  cyst  walls  are  formed  by  an 
attenuated  layer  of  cerebral  tissue. 

The  diagnosis  usually  is  not  difficult,  though  deep  lying  dermoids, 
in  contact  with  the  dura  mater,  and  having  its  motions  transmitted 
to  them,  sometimes  are  mistaken  for  cephaloceles.  The  prognosis  is 
poor,  most  infants  either  dying  soon  after  birth,  or  presenting  in 
later  life  evidences  of  cerebral  defects  (porencephalon,  hydrocephalus, 
idiocy,  etc.).    Spina  bifida  often  coexists. 

Treatment. — Protection  should  be  afforded  the  tumor,  to  prevent 
excoriation  and  infection.  In  most  cases  little  else  can  be  done; 
but  if  there  is  only  a  small  channel  of  communication  with  the  cranial 
cavity,  and  if  the  child's  mentality  appears  normal,  removal  of  the 
tumor  may  be  attempted,  with  closure  of  the  skull  defect  by  trans- 
plantation of  bone  or  cartilage. 

Microcephalus. — Idiotic  or  feeble-minded  children  often  have  an  ab- 
normally small  skull.  Keen  (1890),  Lannelongue  (1891)  and  others 
adopted  linear  craniotomy  for  this  condition,  on  the  theory  that 
premature  ossification  of  the  cranial  sutures  caused  compression 
of  the  brain,  and  that  division  of  the  cranium  in  a  line  parallel  with 
the  sagittal  suture  would  allow  the  brain  to  expand.  But  the  modern 
belief  is  that  the  smallness  of  the  skull  is  the  result  of  lack  of  cerebral 
development,  and  is  not  the  cause  of  it.  Agnew  said  the  operation 
was  no  more  use  than  cutting  a  piece  out  of  a  turtle's  shell,  to  make 
him  grow  larger;  and  this  is  the  general  belief  of  surgeons  of  today. 
There  is  no  surgical  treatment  for  idiocy. 

Hydrocephalus. — This  is  a  symptom  of  some  disease  of  the  brain 
or  its  membranes,  interfering  with  the  normal  circulation  of  the 
cerebrospinal  fluid,  and  causing  it  to  collect  in  abnormal  amounts 
on  the  surface  of  the  brain  or  within  its  ventricles. 

External  Hydrocephalus,  in  which  the  fluid  collects  in  the  sub- 
arachnoid space,  is  very  rare;  many  cases  designated  by  this  name 
really  are.  properly  classed  as  other  conditions.  There  may  be  acute 
edema  of  the  subarachnoid  tissues,  as  the  result  of  trauma;  the 
"acute  serous  meningitis"  of  Quincke  (1893)  belongs  here,  as  also 
does  "hydrops  ex  vacuo,"  in  which  fluid  collects  and  fills  the  space 
left  by  shrinkage  of  the  brain  from  injury  or  disease. 

Internal  Hydrocephalus. — There  are  two  principle  forms  of  this, 
that  due  to  obstruction  (usually  acquired)  and  that  due  to  lack  of 
absorption  of  the  cerebrospinal  fluid  (usually  congenital).  Frazier 
(1916)  employs  the  following  tests  to  distinguish  them: 

1 .  First  examination  (for  delayed  absorption) : 

(a)  Lumbar  puncture — withdraw  1  c.c. 

(b)  Attach  to  puncture  needle  a  2  c.c.  syringe  containing  1  c.c. 
•    neutral  phenolsulphonephthalein  solution,  and  withdraw 

piston  until  1  c.c.  spinal  fluid  enters. 


OBSTRUCTIVE  HYDROCEPHALUS  599 

(c)  Slowly  inject  the  2  c.c.  solution  now  conta'ned  in  syringe 

and  withdraw  needle. 

(d)  Test  urine  every  five  minutes  until  phthalein  is  detected; 

normally  it  appears  within  ten  minutes. 

(e)  Estimate  total  amount  of  dye  excreted  in  the  first  two- 

hour  specimen  of  urine;  normally  this  is  from  30  to  60 

per  cent,  of  the  amount  injected. 
2.  Second  examination  (for  obstruction) ;  this  is  made  after  the  dye  is 
no  longer  found  in  the  urine,  usually  twenty-four  hours  a  ter  the  first 
examination. 

(a)  Puncture  of  lateral  ventricle  and  injection  of  1  c.c.  of  the 

neutral  dye. 

(b)  Lumbar  puncture,  with  examination  of  fluid  for  the  dye 

every  five  minutes  until  it  appears. 

(c)  Test  the  urine  every  five  minutes. 

{d)  Estimate  total  amount  of  dye  excreted  in  the  first  two- 
hour  specimen  of  urine,  allowing  for  that  lost  by  lumbar 
puncture. 

In  the  obstructive  type,  absorption  from  subarachnoid  space  and 
excretion  by  the  kidneys  is  practically  normal;  in  the  non-absorbed 
type,  the  appearance  of  the  dye  in  the  urine  is  delayed — it  may  not 
appear  for  an  hour  or  more,  and  the  two-hour  amount  is  low. 

Obstructive  Hydrocephalus. — Each  lateral  ventricle  communicates 
with  the  third  ventricle  through  an  interventricular  foramen;  while 
in  the  roof  of  the  fourth  ventricle  (which  drains  the  third  ventricle 
through  the  aqueduct  of  Sylvius)  are  found  three  apertures  (one 
medial  and  two  lateral)  which  are  the  channels  of  communication 
between  the  ventricular  cavities  and  the  subarachnoid  space  of  the 
brain,  this  being  continuous  with  the  subarachnoid  space  of  the  chord. 
Occlusion  of  one  interventricular  foramen  may  cause  unilateral  hydro- 
cephalus (rare).  Most  cases  of  internal  hydrocephalus  are  acquired, 
being  acute  or  subacute  rather  than  chronic  (as  in  the  congenital  form), 
and  are  due  to  basal  meningitis,  especially  tuberculous  (p.  623), 
causing  occlusion  of  these  foramina;  yet  pressure  of  a  brain  tumor 
causing  obstruction  to  the  subarachnoid  circulation  anywhere  between 
the  posterior  cranial  fossa  and  the  supratentorial  subarachnoid  space 
also  results  in  internal  hydrocephalus;  and  according  to  Frazier  (1914) 
symptoms  of  intracranial  pressure  in  brain  tumor  (p.  626)  may  be  thus 
explained.  The  symptoms  of  the  acquired  form  of  internal  hydro- 
cephalus are  those  of  the  causative  condition  complicated  by  cerebral 
compression  (p.  617) ;  and  the  treatment  consists  in  relieving  the  com- 
pression, as  removal  of  the  cause  of  the  obstruction  usually  is  out 
of  the  question.  Lumbar  puncture  (p.  158)  is  useless,  as  the  occlusion 
of  the  basal  foramina  prevents  evacuation  of  the  ventricles  by  this 
route;  and  such  treatment  may  prove  quickly  fatal  by  withdrawing  the 
support  of  the  cerebrospinal  fluid  from  beneath  the  medulla,  and 
allowing  the  superincumbent  pressure  to  crowd  this  down  into  the 
foramen  magnum  (p.  619).     But  as  a  palliative  measure  subtemporal 


coo 


SURGERY  OF  THE  HEAD 


decompression  (p.  634)  or  repeated  tapping  of  the  lateral  ventricles 
may  be  done  (v.  Bergmann,  1888)  through  a  trephine  opening  at 
Keen's  point  (1S88):  this  is  3  cm.  behind  and  an  equal  distance  above 
the  external  auditory  meatus;  the  needle  is  entered  through  the 
posterior  part  of  the  first  temporal  convolution,  and  is  directed  toward 
the  summit  of  the  opposite  pinna;  the  ventricle  should  be  reached  at 

a  depth  of  about  4  cm .  Kocher's 
point  (1894)  is  2.5  cm.  to  3  cm. 
from  the  median  line  and  3  cm. 
anterior  to  the  precentral  fissure 
(see  Cranio-cerebralTopography, 
p.  612);  the  needle  is  directed 
downward  and  backward  and 
enters  the  ventricle  at  a  depth 
of  4  or  5  cm.  Frazier  prefers 
to  tap  the  lateral  ventricle  by 
puncture  of  the  corpus  callosum 
(Anton  and  von  Bramm,  1908) : 
a  button  of  bone  is  removed  by 
trephine  2  cm.  from  the  midline, 
and  2  cm.  anterior  to  the  midpoint  between  glabella  and  inion;  the 
dura  is  opened,  and  a  blunt  curved  cannula  is  passed  cautiously 
between  the  hemisphere  and  falx  cerebri  until  the  corpus  callosum 
is  reached;  this  is  then  punctured,  and  the  fluid  allowed  to  escape. 
There  is  little  tendency  for  the  opening  to  close,  especially  if  the 
corpus  be  slightly  lacerated  as  the  cannula  is  withdrawn,  and  thus  a 
more  or  less  permanent  new  channel  of  communication  is  opened 
between  the  ventricular  cavities  and  the  subarachnoid  space.  Fig. 
676  illustrates  the  relative  position  of  the  lateral  ventricles  to  the 
surface  of  the  brain. 


Fig.  676. — Shaded  portion  on  surface  of 
the  brain  indicating  the  position  of  the 
lateral  ventricle  within.     (Campbell.) 


Fig.  677. — Congenital  internal  hydrocephalus  in  a  baby  aged  three  and  one-half 
months.     Children's  Hospital. 


Non-absorbed  Hydrocephalus  is  usually  congenital.  There  is  here 
no  obstruction  or  obliteration  of  the  foramina  at  the  base  of  the 
brain,  but  the  cerebrospinal  fluid  collects  in  excessive  quantities, 
and  as  this  condition  supervenes  in  fetal  existence,  or  soon  after  birth 


OXYCEPHALY  601 

before  the  cranium  is  ossified,  there  are  no  symptoms  of  cerebral 
compression,  but  progressive  enlargement  of  the  cranium  occurs  and 
the  typical  hydrocephalic  head  is  produced  (Fig.  677).  A  fair  degree 
of  intelligence  may  be  preserved,  but  in  cases  of  extreme  deform- 
ity the  size  and  weight  of  the  head  may  render  the  child  helpless, 
and  in  most  cases  death  from  malnutrition  occurs  within  the  first 
two  years  of  life.  Spina  bifida  sometimes  complicates  the  case,  and 
paralyses  of  the  limbs  are  not  uncommon.  Rarely  is  the  disease 
arrested  spontaneously. 

Treatment. — Intracranial  (Keen,  1891),  and  subcutaneous  drainage 
(N.  Senn,  1903)  of  the  ventricles  was  attended  by  an  unduly  high 
mortality  and  no  permanent  benefit  was  secured  in  those  patients  who 
survived.  Cushing  (1908)  having  due  regard  for  the  fact  that  in 
these  congenital  cases  there  rarely  is  any  obstruction  to  the  circula- 
tion of  the  cerebrospinal  fluid  at  the  base  of  the  brain,  inferred  thence 
that  the  obstruction  must  be  where  the  cerebrospinal  fluid  enters 
the  blood  vascular  system  (i.  e.,  in  the  region  of  the  longitudinal 
sinus) ;  on  this  account  he  proposed,  after  ascertaining  that  the  ven- 
tricles could  be  drained  by  puncture  of  the  lumbar  spine,  to  divert 
the  fluid  thence  into  the  retro-peritoneal  tissues  by  means  of  a  silver 
tube  passed  through  the  body  of  one  of  the  lumbar  vertebra?.  He  has 
done  this  operation  a  considerable  number  of  times  "  with  a  consider- 
able measure  of  success."  Heile  (1910),  in  an  infant  of  two  days 
old,  successfully  employed  Handley's  operation  (p.  301),  connecting 
the  sac  of  a  spina  bifida  with  the  peritoneal  cavity  by  means  of  sub- 
cutaneous silk  threads;  a  complicating  hydrocephalus  also  disappeared. 
Frazier  adopts  Handley's  method  by  connecting  the  cysterna  magna 
with  the  pleura. 

Hypersecretory  Hydrocephalus. — In  this  rather  rare  type,  which  is 
recognized  by  the  exclusion  of  the  two  most  common  types  just 
described,  improvement  may  be  derived  from  the  administration  of 
thyroid  extracts.  Stiles  (1905)  employed  ligation  of  both  common 
carotid  arteries,  at  an  interval  of  three  weeks;  but  the  improvement 
was  only  temporary  and  other  surgeons  have  not  adopted  the  operation. 

Oxycephaly. — This  is  a  marked  form  of  steeple-shaped  skull  ( Turm- 
schadel)  occurring  in  childhood  (second  to  sixth  year),  and  manifesting 
itself  by  exophthalmos  and  impairment  of  vision  in  addition  to  the 
cranial  deformity.  Other  congenital  deformities  may  co-exist,  and 
the  disease  may  affect  more  than  one  child  in  the  family.  About 
80  cases  are  now  on  record,  but  not  more  than  20  were  really  oxy- 
cephalic (Sharpe,  1916;  Bedell,  1917).  The  cause  is  unknown.  Intra- 
cranial pressure  exists,  and  expands  only  the  vault,  especially  the 
frontal  region,  giving  a  towering  forehead  and  perhaps  a  sagittal 
crest.  The  orbits  become  shallow,  explaining  the  exophthalmos  (fre- 
quently accompanied  by  divergent  strabismus),  while  the  increased 
intracranial  pressure  is  manifested  by  choked  disks.  X-rays  show  the 
sella  turcica  widened,  the  middle  fossa  being  depressed  almost  to  the 
level  of  the  posterior,  the  frontal  and  ethmoidal  sinuses  becoming 


G02  SURGERY  OF  THE  HEAD 

obliterated,  and  there  being  marked  reduction  of  the  sphenoidal 
angle  (Bertolette,  1910),  converting  the  normal  basilar  kyphosis  into  a 
lordosis.  The  most  severe  cases  usually  die  before  puberty.  The 
symptoms,  apart  from  those  already  mentioned,  consist  almost  solely 
in  paroxysmal  headaches,  the  child  burying  its  head  in  the  pillow 
and  crying  out  with  the  pain.  Palliative  treatment,  consisting  in 
subtemporal  decompression,  callosal  puncture,  or  other  measures 
advised  for  cases  of  hydrocephalus,  should  be  undertaken  as  soon  as 
the  diagnosis  is  made. 


INJURIES  OF  THE  SKULL. 

Wounds. — Occasionally  one  sees  incised  wounds  of  the  cranial 
bones,  without  fracture;  saber  wounds  sometimes  occur  in  war,  and 
in  civil  life  a  pen-knife  or  other  sharp  instrument  may  be  stuck 
into  the  skull.  Such  injuries  require  no  special  treatment  beyond 
removal  of  the  foreign  body,  if  still  present,  and  antiseptic  care  of 
the  wound. 

Fractures. — For  practical  purposes  the  skull  may  be  considered 
a  sphere,  possessed  of  a  considerable  degree  of  elasticity.  For  it 
to  be  fractured,  a  good  deal  of  force  is  necessary,  and  this  acts  in  two 
main  ways:  (1)  the  skull  may  be  compressed  between  two  diametric- 
ally opposite  forces,  or  (2)  it  may  be  struck  a  violent  blow.  In  the 
latter  case  the  effect  is  the  same  whether  the  head  is  struck,  or  whether 
it  strikes  against  another  object;  the  only  counter-pressure  when  the 
head  is  struck  is  that  offered  by  the  inertia  of  the  head  and  the  resist- 
ance of  its  attachments  to  the  trunk,  while  when  the  head  strikes 
another  object  there  is  also  the  momentum  of  what  Archibald  happily 
terms  the  "after-coming  head."  Between  the  diffused  crush  and  the 
localized  blow,  there  may  be  all  grades  of  violence,  varying  from  the 
puncture  made  by  a  pick-axe,  or  the  blow  from  a  black-jack,  to  a 
knock-out  by  a  sand-bag,  or  a  crush  between  two  heavy  beams. 

When  the  cranium  is  compressed  in  one  diameter  it  naturally 
expands  in  the  diameter  at  right  angles  to  the  first  (Saucerotte, 
1769);  Victor  Bruns  (1854)  and  Angus  McLean  (1912)  measured  this 
compensatory  expansion  experimentally,  finding  that  it  amounted 
to  several  millimeters.  The  first  and  most  obvious  result  of  this 
compression  was  illustrated  by  Ali  Krogius  (1907)  by  cracking  a 
hazelnut  by  lateral  compression  (Fig.  678):  fissures  are  produced 
which  represent  meridians  of  longitude  in  relation  to  the  points  of 
compression  which  are  regarded  as  poles;  these  fissures  gape  widest 
in  the  equatorial  region,  and  when  compression  is  relaxed  they  may 
close  again  completely.  In  the  skull  such  fissures  are  very  frequently 
seen  as  the  result  of  diffused  violence,  and  in  them  may  be  caught, 
as  in  a  vise,  hairs  from  the  scalp,  portions  of  felt  from  a  hat,  and 
strangest  of  all,  foreign  bodies  may  even  pass  through  the  fissure  while 
it  momentarily  gapes,  and  thus  be  entirely  hidden  from  view  inside 


INJURIES  OF  THE  SKULL 


603 


the  cranium  when  the  closed  fissure  is  examined  by  the  surgeon. 
These  are  called  bursting  fractures  (von  Wahl,  1883). 

Another  result  of  the  compensatory  expansion  of  the  skull  in  the 
diameter  at  right  angles  to  that  in  which  it  is  compressed,  is  that  at 
the  poles  there  occurs  an  inbending  of  the  skull  (Figs.  679  and  680) ; 
that  such  should  be  the  case  at  the  point  of  impact  of  localized  vio- 
lence, is  not  difficult  to  understand,  but  that  a  fracture  from  inbend- 
ing may  occur  at  a  point  more  or  less  remote  would  be  unthinkable 
unless  the  elasticity  of  the  skull  and  ordinary  physical  laws  were 
kept  in  mind.  This  is  the  fracture  by  counter-stroke  (contrecotip) , 
which  formerly  was  explained  solely  on  the  basis  of  vibrations  which 
were  set  up  by  the  blow,  and  spreading  in  all  directions  from  the 


Fig.  678. — Mechanism  of  fracture 
of  the  skull  by  lateral  compression: 
a  meridional  bursting  fracture. 


Fig.  679. — Diagram  to  illustrate  the  elas- 
ticity of  the  skull.  When  the  skull  is  com- 
pressed between  a  and  b,  these  points  ap- 
proach each  other  while  the  points  c  and  d 
become  more  widely  separated.  (See  Fig. 
680.) 


Fig.  680. — Mechanism  of  fracture  of  the 
skull  by  counter-stroke:  when  the  skull  is 
compressed  at  a,  a  and  b  approach  each 
other,  and  a  fracture  by  inbending  may  occur 
at  b  as  well  as  at  a;  or  fracture  by  outbending 
may  occur  at  c  or  at  d. 


point  of  impact  met  finally  at  the  polar  point  and  there  disrupted 
the  skull.  Though  the  bursting  theory,  originated  by  Chopart  and 
other  French  surgeons  in  the  eighteenth  century,  and  re-introduced 
and  elaborated  by  Felizet  in  France  (1873),  by  Messerer  and  von 
Wahl  in  Germany,  and  by  Dulles  in  America,  in  the  eighth  decade 
of  the  last  century,  has  largely  superseded  the  vibratory  theory  as 
an  explanation  of  fissured  fractures  and  fractures  by  counter-stroke, 
there  can  be  no  doubt,  as  pointed  out  by  Nancrede  (1884),  that 
vibrations  do  occur,  and  are  most  violent  where  the  bone  is  thickest, 
that  is,  at  the  base  of  the  skull,  where  most  of  the  fractures  by 
counter-stroke  occur.  W.  S.  Wadsworth  claims  that  fractures  at  the 
base  are  usual  results  of  blows  upon  the  vault  because  vibrations 
meet  at  the  base:     the  vibrations  travel  quickly  across  the  vault 


C04 


SURGERY  OF  THE  HEAD 


(thin)  and  slowly  across  the  base  (thick),  vibrations  starting  in  oppo- 
site directions  thus  meeting  at  the  same  time  at  the  base. 

When  localized  violence  is  applied  to  the  skull  the  force  of  the 
blow  expends  itself  mostly  by  depressing  the  bone  at  the  point  struck; 
this  is  the  inbending  fracture  referred  to  above.  Now,  this  point 
being  regarded  as  a  pole,  there  are  produced  in  the  surrounding 
inert  but  elastic  skull,  concentric  areas  of  compression,  or  oidbendings , 
which  represent  parallels  of  latitude;  and  at  the  points  where  the 
inbending  and  outbending1  areas  meet,    a   circular   fissure   or    ring 

fracture^  may  [result  (Fig.  681). 
Occasionally  a  long  fissure  oc- 
curs at  the  equatorial  region 
when  the  skull  is  diffusely 
crushed,  and,  according  to 
Archibald,  this  must  be  ex- 
plained as  a  fracture  by  out- 
bending,  as  must  certain  fis- 
sures which  run  at  right  angles 
to  the  meridional  bursting  fis- 
sures (Fig.  682). 

In  addition  to  the  usual  clas- 
sification of  fractures,  as  simple, 
compound,  depressed,  etc., 
there  are  important  clinical  dis- 
tinctions between  fractures  of 
the  vault  of  the  skull  and  those 
of  its  base. 

Fractures  of  the  Vault  of  the  Skull. — Most  fractures  of  the  vault 
are  due  to  direct  violence,  the  parietal  and  temporal  bones  being 
most  often  injured.    Almost  always  the  injury  acts  from  outside  the 


Fig.  681. — Ring  fracture  of  skull.  From 
a  specimen  in  the  Mutter  Museum  of  the 
College  of  Physicians  of  Philadelphia. 


Fig.  682. — Bursting  fracture  of  skull  from  diffused  violence  on  vertex:  fissure  radiating 
to  base  and  widest  at  equator  (temporal  region) ;  with  outbending  fracture  (just  below 
parietal  eminence)  at  right  angles  to  main  fissure.  From  a  specimen  in  the  Mutter 
Museum. 

1  The  Flachbiegung  urid  Krummbiegung  of  Treub  (1884). 


INJURIES  OF  THE  SKULL 


605 


Fig.  683. — Teevan's  diagram  to  show 
that  the  inner  table  often  is  more  exten- 
sively damaged  than  the  external,  because 
it  is  in  the  line  of  extension. 


skull,  so  that  the  inner  table  is  in  the  line  of  extension  (Fig.  683), 
and,  therefore,  is  more  widely  fractured  than  the  external  table 
(Teevan,  1864).  Indeed,  so  elastic  is  the  skull  that  a  fracture  of  the 
vitreous  table  may  occur  without  any  fracture  of  the  outer  table. 
In  the  rare  cases,  mostly  suicidal  pistol  shots,  in  which  the  cranial 
vault  is  fractured  from  violence  within  the  skull,  the  outer  table  is 
more  widely  fractured  than  the  inner.  It  is  very  unusual  for  the 
external  table  to  be  fractured 
without  injury  of  the  internal; 
it  is  then  depressed  into  the 
diploe.  The  amount  of  splinter- 
ing is  in  inverse  ratio  to  the 
momentum  of  the  body  fractur- 
ing the  skull;  but  in  the  case  of 
gunshot  wounds,  as  pointed  out 
at  p.  194,  the  "explosive  action" 
is  manifested  at  close  range. 

Symptoms. — Apart  from  those 
due  to  intracranial  complications 
(p.  614),  there  are  no  symptoms 
specially  indicative  of  a  fracture  of 
the  vault  of  the  skull.  The  diag- 
nosis rests  on  the  history  of  injury, 

on  the  symptoms  due  to  complicating  intracranial  lesions,  and  on 
physical  signs.  A  skiagraph  may  be  of  value.  If  there  is  no  scalp 
wound,  the  entire  calvaria  must  be  palpated  carefully  and  persistently 
to  discover  any  evidence  of  fracture;  if  a  mere  fissure  exists,  without 
depression  or  separation,  nothing  will  be  detected  beyond  the  signs 
of  contusion  of  the  scalp  (p.  595).  The  error  of  mistaking  a  hema- 
toma for  a  depressed  fracture  must  be  guarded  against.  If  there  is  a 
depressed  fracture  it  usually  is  possible  to  feel  it  through  the  scalp, 
recognizing  its  jagged  outline  and  its  actual  depression  below  the 
surrounding  bony  surfaces;  the  depressed  fragments  may  not  be 
impacted,  and  injudicious  pressure  may  drive  them  against  the  brain. 
If  the  existence  of  a  fracture  remains  in  doubt,  no  hesitancy  should 
be  felt  in  making  an  incision  down  to  the  bone,  under  proper  anti- 
septic precautions,  and  inspecting  the  bared  cranium.  In  compound 
fractures  it  may  be  necessary  to  enlarge  the  existing  wound  for  the 
same  purpose.  A  normal  suture  may  be  distinguished  from  a  fissured 
fracture  by  its  anatomical  position,  its  greater  irregularity  of  outline, 
and  by  the  fact  that  a  fracture  cannot  be  washed  clean  of  blood. 
In  children  there  may  be  diastasis  of  suture  lines  instead  of,  or  in 
addition  to,  fissured  or  depressed  fracture  of  the  skull.1 

Prognosis. — This  is  good,  so  far  as  the  fracture  alone  is  con- 
cerned. It  is  only  intracranial  complications  that  render  the  outcome 
doubtful.  Excessive  loss  of  bone  seldom  occurs,  and  complications 
affecting  the  scalp  (erysipelas,  etc.)  are  very  rare  with  antiseptic 
methods. 

1  See  footnote,  p.  606. 


C0(>  SURGERY  OF   THE  HEAD 

Treatment. — Every  case  of  head  injury,  no  matter  how  trivial  in 
appearance,  should  be  treated  with  extreme  circumspection.  It 
is  the  custom  of  many  cautious  surgeons,  and  for  years  has  been 
mine,  to  urge  all  patients  with  injuries  of  the  head  to  remain  under 
constant  surgical  observation,  preferably  in  the  hospital,  for  several 
days.  It  is  most  important  to  prevent  infection;  and,  as  a  rule,  it  is 
well  to  shave  the  entire  scalp,  as  this  often  renders  diagnosis  easier, 
and  always  promotes  asepsis.  Shaving  the  scalp,  or  at  least  a  wide 
area  around  the  injury,  therefore,  usually  is  the  first  step  in  treatment. 

7/  only  a  simple  fissured  fracture  exists,  without  depression,  and 
without  any  evidence  of  intracranial  mischief,  it  is  sufficient  to  keep 
the  patient  in  bed  for  six  to  eight  days,  with  an  ice  bag  to  the  head; 
the  bowels  should  be  well  opened,  preferably  by  calomel,  as  this 
has  a  specific  action  upon  the  meninges  and  brain,  exerting  what 
was  known  in  the  last  century  as  an  "anticipatory  antiplastic  action," 
that  is,  preventing  excessive  inflammatory  reaction,  probably  by 
its  antiseptic  properties.  Urotropin  is  used  for  the  same  purpose, 
as  it  has  been  found  to  circulate  in  the  cerebrospinal  fluid;  it  must 
be  given  in  very  large  doses.  If  the  simple  fissured  fracture  was 
caused  by  localized  violence,  which  is  rarely  the  case,  it  will  be  safer 
to  ascertain  whether  or  not  the  inner  table  is  splintered,  by  removing 
a  button  of  bone  with  the  trephine.  If  such  splintering  exists,  the 
case  is  treated  as  a  depressed  fracture. 

If  the  fissured  fracture  is  compound  the  surgeon  should  make  very 
certain  that  no  hair  or  other  foreign  body  is  caught  in  the  fissure, 
or  has  passed  through  it,  before  he  decides  against  operation.  If 
there  is  any  doubt  as  to  the  surgical  cleanliness  of  the  fissure,  the 
surgeon  must  take  means  to  render  it  aseptic.  Sometimes  little  tufts 
of  hair  are  found  sticking  up  out  of  almost  invisible  fissures  (G.  G. 
Davis,  1910),  and  a  gouge  must  be  employed  to  remove  them  and 
their  containing  bone;  in  other  cases  a  trephine  may  be  used  to  per- 
forate the  skull,  and  then  the  entire  septic  fissure  is  gnawed  away 
into  healthy  bone  by  rongeur  forceps.1 

If  the  fracture  is  depressed  I  believe  operation  always  in  indicated, 
to  relieve  pressure  on  the  brain;  and  if  it  is  compound,  whether  it  is 
depressed  or  not,  operation  usually  is  necessary  to  secure  asepsis  of 
the  wound.  But  operation  has  no  virtue  of  its  own,  being  only  a 
mechanical  means  of  fulfilling  plain  therapeutic  indications.  Loose 
fragments  are  removed,  and  the  elevator  (Fig.  684,  3)  is  passed  under 

1  In  1907  I  operated  on  a  boy  of  eleven  years,  at  the  Episcopal  Hospital,  Phila- 
delphia, for  extensive  bursting  fracture  due  to  crush;  there  were  compound  com- 
minuted depressed  ring-fractures  in  the  right  parietal  and  the  left  temporal  bones, 
the  poles  of  impact;  and  these  areas  were  connected  across  the  vault  by  a  meridi- 
onal fissure  which  was  deflected  into  the  suture  lines,  causing  diastasis  of  the  right 
temporo-parietal  suture  and  the  entire  coronal  suture,  with  rupture  of  the  longi- 
tudinal sinus.  The  loose  fragments  were  removed,  the  depressed  fragments 
elevated,  and  the  separated  sutures  cleaned  of  hairs  and  clot  by  gnawing  away 
both  margins  of  bone.  From  the  left  temporal  region  a  fissure  ran  to  the  base, 
thus  practically  separating  the  skull  into  antero-posterior  halves.  There  was 
no  injury  to  the  brain,  and  the  boy  recovered. 


INJURIES  OF  THE  SKULL 


607 


the  depressed  fragments  and  these  are  pried  up  into  place.  Search 
is  then  made  by  Horsley's  dural  separator  (Fig.  684,  2)  for  loose  frag- 
ments which  sometimes  are  driven  under  the  neighboring  intact  por- 
tions of  cranium,  and  these  are  removed.  All  fragments  completely 
detached  should  be  removed  entirely  unless  certainly  aseptic;  if  a 
very  large  gap  would  be  left  by  their  removal,  they  may  be  replaced 
after  being  boiled.  If  the  fragments  are  impacted,  so  that  none  of 
them  can  be  removed,  and  there  is  no  crack  into  which  the  elevator 
can  be  insinuated,  a  button  of  bone  must  be  removed  by  the  crown 
trephine  (Fig.  684,  1),  and  the  remaining  depressed  fragments  ele- 
vatedJ[through  the  opening  thus  made.     Next,  the  bone  must  be 


Fig.  684. — Instruments  used  in  operating  for  fracture  of  the  skull:   1,  Crown  trephine; 
2,  Horsley's  dural  separator;  3,  bone  elevator;  4,  Hopkins's  rongeur  forceps. 


disinfected.  Usually  this  is  best  accomplished  by  biting  off  ragged 
edges  of  bone  with  the  rongeur  forceps  (Fig.  684,  4),  thus  completely 
removing  all  suspicious  areas  in  which  foreign  particles  may  have 
been  caught.  In  fractures  of  the  frontal  sinuses  the  outer  wall  alone 
may  be  fractured;  but  as  the  sinuses  are  of  uncertain  extent,  even 
when  developed,  and  as  the  fracture  always  is  compound,  either  from 
within  or  on  the  skin  surface,  it  is  proper  to  explore  the  region  affected 
and  to  remove  sufficient  bone  to  render  the  wound  surgically  clean. 

After  any  operation  for  fracture  of  the  skull,  a  copious  dressing 
should  be  securely  applied  (Fig.  685),  as  the  patient  may  be  delirious, 
and  requires  mechanical  protection  to  the  site  of  operation. 


fiOS 


SURGERY  OF   THE  HEAD 


Fig.  6S5. — Dressing  for  fracture 
of  skull.     Episcopal  Hospital. 


Rupture  of  the  longitudinal  sinus  is  a  not  infrequent  complication  of 
fractures  of  the  cranial  vault.     Bone  fragments  may  be  embedded  in 

its  walls,  or  it  may  be  torn  accident- 
ally in  elevating  or  removing  depressed 
fragments.  Hemorrhage  may  be  pro- 
fuse, but  it  is  readily  controlled  by 
packing,  as  the  blood-pressure  is  low. 
Attempts  to  suture  the  rent  rarely  are 
successful,  the  sutures  tearing  out;  and 
the  profuse  hemorrhage  may  cost  the 
patient  his  life  before  the  attempts  to 
suture  are  abandoned.  Packing  is 
quicker  and  safer.  The  gauze  should 
be  removed  in  three  or  four  days. 
Trephining  the  Skull. — The  trephine  is  applied  first  with  the  center- 
pin  protruded;  with  this  as  a  pivot  a  circular  groove  is  cut  by  alter- 
nately supinating  and  pronating  the  hand,  and  when  this  groove  is 
of  sufficient  depth  to  steady  the  trephine  without  the  aid  of  the 
centerpin  this  is  withdrawn,  and  the  trephining  is  continued  very  cau- 
tiously, using  scarcely  any  pressure  for  fear  of  plunging  the  instru- 
ment into  the  brain.  The  use  of  Gait's  conical  trephine1  renders  this 
accident  unlikely,  if  ordinary  prudence  is  exercised.  When  the 
diploe  is  reached,  the  trephine  cuts  more  easily,  and  the  bone  bleeds 
more;  as  the  vitreous  is  approached  the  surgeon,  from  time  to  time, 
should  test  the  depth  of  his  groove  with  the  flat  end  of  a  probe,  as 
the  skull  is  not  of  uniform  thickness  and  incautious  trephining  may 
rupture  the  dura  at  one  side  before  the  vitreous  table  is  cut  through 
on  the  other.  If  the  button  of  bone  does  not  come  away  in  the  crown 
of  the  trephine,  it  is  pried  out  by  the  elevator.  The  trephine  never 
should  be  applied  on  the  depressed  fragment,  but  on  the  surrounding 
intact  cranium,  so  that  no  further  impaction  or  cerebral  injury  may 
be  produced.  Nor  should  the  trephine  be  applied  directly  over  the 
longitudinal  or  lateral  sinuses. 

Fractures  of  the  Skull  in  the  Newborn. — Indentations  of  the  semi- 
membranous skull  of  the  baby  may  occur  from  injury  during  labor, 
or  at  a  later  age  from  blows,  falls,  etc.  The  bone  is  so  flexible  that 
true  fracture  during  labor  is  rarer  than  bending.  The  depression 
usually  corrects  itself  within  ten  days;  if  it  does  not,  and  immediately 
if  it  produces  symptoms  of  cerebral  compression  (p.  617),  operation 
should  be  done.  Nicoll's  operation  (1903)  consists  in  excision  of  the 
cup-shaped  depression,  and  its  replacement  with  the  dural  (convex) 
surface  beneath  the  skin.  Usually  it  is  sufficient  to  pry  the  bone 
up  by  an  elevator  introduced  through  a  neighboring  fontanelle  or 
suture.    The  bone  is  soft  and  easily  cut  by  scissors.    The  danger  of 

1  This  was  a  revival  of  an  old  instrument.  Gait's  pattern  was  first  used  by 
Sayre  in  1861:  the  spiral  grooves  on  the  periphery  act  as  a  screw  so  long  as  there 
is  counter-pressure  by  bone  on  the  oblique  teeth  of  the  crown;  when  resistance 
ceases,  the  conical  trephine  acts  as  a  wedge,  and  binds.  Hudson's  trephine  (p. 
634)  is  constructed  on  the  same  principle. 


INJURIES  OF  THE  SKULL 


609 


^F* 

f-" 

^  f^H 

Wyf&\ 

/    ^i"" ' V 

V 

■  i  .^^^ 

t 

9                  ~*'jf 

fi 

■      1 

/ 

■^k 

leaving  such  fractures  untreated  is  that  cortical  lesions  may  result, 
leading  to  spastic  paralysis,  epilepsy,  imbecility,  etc.  In  older  infants 
fracture  may  split  the  cranial  bone  radially  in  the  usual  line  of 
ossification. 

Fractures  of  the  Base  of  the  Skull. — Most  of  these  are  the  result  of 
bursting  force,  a  fissure  extending  from  the  point  of  injury  on  the 
vault  to  the  base  of  the  skull,  usually 
along  definite  lines.  The  recognition 
of  this  fact  is  due  chiefly  to  Aran 
(1844),  who  claimed  that  in  every 
fracture  of  the  base  the  fissure 
began  in  the  vault.  This,  how- 
ever, is  not  literally  true,  as  the 
fracture  sometimes  begins  at  the 
base  and  may  or  may  not  extend 
to  the  vault.  Falls  on  the  feet  or 
on  the  buttocks  may  fracture  the 
base  by  force  applied  through  the 
condyles  of  the  occipital  bone. 
When  fracture  of  the  base  occurs 
as  part  of  a  bursting  fracture  from 
diffused  force  applied  to  the  calvaria, 
the  fissure  extends  to  the  base  by 
the  shortest  anatomical  route, 
avoiding  buttresses  such  as  the 
mastoid,  the  external  angular  pro- 
cess of  the  frontal  bone,  etc.    Thus 

it  is  found  that  in  fractures  from  lateral  compression,  usually  on  the 
parietal  bones,  the  fissure  crosses  the  middle  fossa  of  the  skull  in  the 
majority  of  cases  (23  out  of  32  cases  recorded  by  Archibald).  From 
occipitofrontal  compression,  a  fissure  results  which  passes  usually 
through  one  orbital  plate  of  the  frontal,  through  the  body  of  the 
sphenoid,  and  the  sella  turcica,  along  the  petro-occipital  suture  to 
the  jugular  foramen,  and  perhaps  up  again  to  the  vault  along  the 
masto-occipital  suture;  or  if  the  fissure  passes  down  the  occipital 
bone,  it  skirts  the  side  of  the  foramen  magnum,  and  so  to  the  sella 
turcica  (Fig.  686).  Rawling  found  the  sphenoidal  sinus  fractured  in 
70  per  cent,  of  his  cases.  These  basal  fractures  very  often  are  com- 
pound, through  the  naso-pharynx  or  middle  ear.  Displacement  is 
very  slight. 

Punctured  fractures  of  the  base  of  the  skull  are  exceedingly  serious 
lesions;  they  occur  from  such  implements  as  umbrella  tips,  pencils, 
pipe-stems,  etc.,  which  may  penetrate  the  orbit  or  naso-pharynx, 
sometimes  entering  one  of  the  fissures  or  foramina  at  the  base  of  the 
brain  with  little  damage  to  the  surrounding  bone. 

Symptoms. — These  depend,   as  in  fractures   of  the  vault,   much 
more  upon  cerebral  injury  than  upon  the  mere  existence  of  fracture. 
The  diagnosis,  therefore,  depends  in  large  measure  on  circumstantial 
39 


Fig.  686.  —  Diagram  showing  the 
usual  course  taken  by  fissured  fractures 
of  the  base  of  the  skull. 


(ill) 


SURGERY  OF   THE  HEAD 


evidence  derived  from  certain  physical  signs,  and  from  a  knowledge 
of  the  mode  of  injury.  Fractures  of  the  anterior  fossa  may  be  accom- 
panied by  bleeding  into  the  retrobulbar  tissues  of  the  orbit,  sub- 
conjunctivaJ  ecchymosis  appearing  some  days  after  the  injury,  and 
spreading  from  behind  forward;  exophthalmos  is  a  rare  sign.  Bleed- 
ing from  the  nose  or  mouth  is  as  often  due  to  extracranial  as  to  cranial 
lesions.  Brain  substance  or  cerebrospinal  fluid  rarely  is  discharged. 
Blood  may  be  swallowed  and  vomited.  Fractures  of  the  middle  fossa 
frequently  are  compound  through  the  middle  ear,  and  though  bleed- 
ing from  the  ear  may  be  due  merely  to  rupture  of  the  tympanic  mem- 
brane, when  persistent  or  profuse  it  has  usually  an  intracranial  source; 
it  may  enter  the  throat  through  the  Eustachian  tube.    A  elear  liquid 

discharge  may  occur  from  the  mastoid 
cells  or  from  the  membranous  labyrinth, 
but  any  such  discharge  in  large  amount 
is  more  apt  to  be  cerebrospinal  fluid. 
Paralysis  of  one  or  more  of  the  cranial 
nerves  is  more  frequent  in  fractures  of 
the  middle  fossa  than  in  those  of  the 
anterior  or  posterior  fossae.  (Fig.  687.) 
The  seventh  and  eighth  nerves  are  those 
most  often  injured,  usually  from  lacer- 
ation or  secondary  edema.  Ferron  (1908) 
collected  339  instances  of  nerve  lesion, 
with  33  deaths.  Fractures  of  the  posterior 
fossa  frequently  are  not  recognized,  be- 
cause of  lack  of  physical  signs.  Ecchy- 
mosis over  the  mastoid,  appearing  some 
days  after  the  injury,  is  of  some  signifi- 
cance; as  is  the  occasional  involvement 
of  the  ninth,  tenth,  and  eleventh  nerves. 
Prognosis.  —  This  depends  upon  the 
presence  of  intracranial  lesions  and  upon 
the  development  of  complications,  es- 
pecially meningitis.  Without  these,  the 
prognosis  is  no  worse  than  in  fracture  of  the  vault.  As  a  general 
rule,  about  one  out  of  three  or  four  patients  with  fracture  of  the 
base  will  die  within  a  week  or  ten  days. 

Treatment. — The  general  treatment  is  the  same  as  in  fractures 
of  the  vault :  physical  and  mental  rest,  in  a  cool ,  darkened  room ; 
and  purgation  to  remove  material  which  might  cause  toxemia  or  bac- 
teremia and  hence  increase  the  danger  of  sepsis.  Urotropin  should 
be  administered  (15  grains  three  times  daily,  with  an  interval  of  one 
day  at  the  end  of  each  three-day  period),  and  liquid  diet  should  be 
continued  until  danger  of  complications  has  passed.  The  naso-pharynx 
and  external  auditory  meatus  should  be  cleansed,  but  repeated 
irrigation  is  more  apt  to  encourage  sepsis  than  to  prevent  it.  If 
bleeding  is  profuse  it  may  be  necessary  to  pack  the  naso-pharynx 


Fig.  G87. — Fracture  of  base  of 
skull,  following  a  fall.  On  second 
day  developed  paralysis  of  third 
cranial  nerve  on  left  side,  and 
seventh  cranial  nerve  on  right 
side.  Recovery.  No  operation. 
Episcopal  Hospital. 


INJURIES  OF  THE  SKULL 


611 


or  auditory  meatus;  in  all  cases  it  is  well  to  keep  a  little  sterile  ab- 
sorbent cotton  in  the  latter  channel  to  absorb  discharges.  If  bleeding 
is  very  persistent,  and  especially  if  packing  produces  symptoms  of 
cerebral  compression,  attempt  should  be  made,  by  trephining  the 
skull  low  in  the  temporal  region,  to  reach  the  source  of  hemorrhage 
and  deal  directly  with  it.  If  symptoms  of  compression  arise,  whether 
there  is  external  hemorrhage  or  not,  decompression  should  be  done 
(p.  634).  Lumbar  puncture  may  be  employed  as  a  diagnostic  measure 
to  ascertain  the  presence  of  blood  in  the  cerebrospinal  fluid;  occasion- 
ally it  is  curative  also. 

Osteomyelitis. — Osteomyelitis  of  the 
cranial  bones  is  rare,  and  extremely 
fatal ;  usually  it  follows  contusion  of  the 
bone,  secondary  infection  occurring 
through  the  blood-stream  or  from  an 
overlying  hematoma.  It  is  rarer  still 
as  a  complication  of  compound  fracture 
or  a  scalp  wound,  as  in  such  cases 
drainage  is  free.  The  diagnosis  rests  on 
the  appearance  of  septic  symptoms,  after 
injury  to  the  skull,  with  the  develop- 
ment locally  of  the  "puffy  tumor"  of 
Percival  Pott  (1768),  which  is  "a  circum- 
scribed, flattened,  elevated  swelling," 
due  to  infiltration  of  the  scalp  with 
serum,  and  indicates  "a  subjacent  sup- 
purative periosteitis,  denuded  bone,  and 
in  many  instances  subcranial  suppura- 
tion with  separation  of  the  dura  mater" 
(Nancrede,  1885). 

Treatment. — Treatment  consists  in  removal  of  all  diseased  bone, 
by  trephine  and  rongeur,  with  free  drainage.  Death  is  the  usual 
outcome  of  the  disease,  from  meningitis  and  encephalitis,  except 
where  very  early  operation  is  done. 

Repair  of  Cranial  Defects. — Usually  after  operation  for  fracture 
or  other  lesion  of  the  skull,  in  which  a  large  area  of  bone  is  removed, 
the  defect  produces  little  inconvenience,  being  filled  in  by  dense 
fibrous  tissue.  There  is  no  tendency  to  hernia  cerebri  (Fig.  704)  unless 
intracranial  tension  is  increased;  on  the  contrary,  the  area  usually 
is  depressed  (Fig.  688).  Sometimes,  from  dural  adhesions,  or  other 
cause,  this  depressed  area  is  a  source  of  constant  annoyance,  and 
may  subject  the  brain  to  slight  injuries.  If  the  symptoms  are  so 
severe  as  to  demand  relief,  a  free  transplant,  consisting  of  the  outer 
table,  may  be  removed  from  another  portion  of  the  skull;  or  a  free 
transplant  of  cartilage  may  be  employed  (see  p.  247). 


Fir,.  6S8. — Loss  of  bone  after 
fractured  skull:  four  months  after 
operation.  (Dr.  Mutsehler's 
ease.)     Episcopal  Hospital. 


612  SURGERY  OF  THE  HEAD 

SURGICAL  AFFECTIONS  OF  THE  BRAIN  AND  MENINGES. 

Cranio-cerebral  Topography,  which  implies  a  knowledge  of  the 
relation  of  intracranial  structures  (cerebral  fissures  and  convolutions, 
blood-sinuses,  meningeal  vessels,  etc.)  to  the  overlying  skull,  is  not 
now  regarded  as  of  so  much  importance  as  some  years  ago.  This 
is  so  both  because  these  relations  exhibit  variations  in  different 
persons,  and  because  modern  surgical  technique  enables  the  surgeon 
to  raise  a  large  bone  flap  from  the  cranium,  and  expose  the  underlying 
structures  over  a  sufficiently  wide  area  to  permit  of  his  recognizing 
them  rather  by  their  relations  to  each  other  than  by  their  relations 
to  the  surface  of  the  cranium.  But  there  are  a  few  landmarks  which 
it  is  indispensable  for  the  surgeon  to  know. 

The  longitudinal  sinus  runs  beneath  the  sagittal  suture  from  the 
root  of  the  nose  to  the  inion;  it  lies  within  the  falx  cerebri,  and  extends, 
with  its  annexed  blood-lakes,  for  about  2  cm.  each  side  of  the 
median  line,  being  broader  behind  than  anteriorly.  Usually  it  extends 
further  to  the  right  than  to  the  left  of  the  median  line. 

The  lateral  sinus  runs  on  each  side,  along  the  attachment  of  the 
tentorium  cerebelli,  from  the  inion  to  the  base  of  the  mastoid;  here 
it  passes  downward,  following  the  petro-mastoid  suture  to  the  jugular 
foramen  (Fig.  690).  The  anterior  and  upper  margin  of  the  curve 
where  the  horizontal  and  descending  (sigmoid)  portions  of  the  lateral 
sinus  meet,  known  as  the  knee  (genu)  of  the  lateral  sinus,  is  about 
2.5  cm.  above  and  nearly  4  cm.  behind  the  center  of  the  external 
auditory  meatus.  The  sinus  is  about  12  mm.  or  more  broad,  and  the 
"dangerous  area,"  over  which  a  trephine  or  chisel  should  not  be 
applied,  includes  a  strip  of  bone  nearly  2.5  cm.  wide,  overlying  the 
course  of  the  sinus. 

The  upper  limit  of  the  cerebral  hemispheres  corresponds  to  the 
position  of  the  superior  longitudinal  sinus.  Their  lower  limit  reaches, 
in  front  to  the  upper  margin  of  the  orbit;  laterally  it  passes  from  a 
point  12  mm.  above  the  external  angular  process  of  the  frontal  bone, 
to  the  upper  margin  of  the  external  auditory  meatus,  and  thence  to 
the  inion,  along  the  upper  border  of  the  lateral  sinus. 

The  fissure  of  Rolando  runs  from  a  point  about  12  mm.  behind 
the  mid-point  between  glabella  and  inion,  forward  for  nearly  8.5 
cm.,  at  an  angle  of  about  70°  with  the  sagittal  suture.  If  a 
square  of  paper  (90°)  is  folded  diagonally,  so  as  to  make  two  angles 
of  45°  each,  and  one  of  these  folds  is  again  doubled  on  itself,  so  as 
to  make  two  angles  of  22.5°  each,  it  will  be  possible,  by  adding  one 
of  these  latter  angles  to  the  45°  angle,  to  construct  off-hand  an  angle 
of  67.5°,  or  three-quarters  of  the  original  right  angle.  If,  then,  this 
angle  (67.5°)  is  placed  on  the  sagittal  suture,  so  that  its  apex  lies 
12  mm.  behind  the  mid-point  between  glabella  and  inion,  the  course 
of  the  Rolandic  fissure  will  be  approximately  indicated  (Chiene, 
1888).  The  relation  of  the  other  chief  fissures  and  convolutions  is 
sufficiently  indicated  in  Fig.  689. 


CRANIO-CEREBRAL   TOPOGRAPHY  613 

The  middle  meningeal  artery,  entering  the  skull  by  the  foramen 
spinosum,  divides  almost  immediately  into  two  branches.  The  anterior 


Fig.  689. — Relation  of  the  chief  fissures  and  convolutions  of  the  brain  to  the  surface 
of  the  skull.  The  dotted  line  which  is  nearly  horizontal  indicates  the  fissure  of  Sylvius; 
this  line  runs  from  the  external  angular  process  of  the  frontal  bone  through  a  point 
2  cm.  below  the  parietal  eminence  (x),  and  its  middle  third  corresponds  roughly  with 
the  Sylvian  fissure.    Note  the  positions  of  the  cranial  sutures. 

branch  runs  forward  and  upward  and  crosses  the  anterior  inferior 
angle  of  the  parietal  bone,  near  the  pterion;  thence  it  runs  upward 
toward  the  sagittal  suture,  lying  behind  and  more  or  less  parallel 


Fig.  690. — Course  of  middle  meningeal  artery  and  lateral  sinus,  outlined  upon 
the  surface  of  the  skull. 

to  the  coronal  suture.     Near  the  pterion  it  lies  usually  in  a  bony 
groove  or  canal,  and  is  frequently  torn  by  splinters  of  bone,  or  ruptured 


(ill  SURGERY  OF   THE  HEAD 

by  inbending  or  bursting  fractures  at  this  point.  It  may  also  be 
injured  at  this  point  by  a  trephine,  so  it  is  safer  to  expose  it  by  a 
trephine  opening  in  the  middle  of  the  temporal  fossa,  say  4  cm. 
posterior  to  the  external  angular  process  of  the  frontal  bone,  and 
2.5  cm.  above  the  zygoma  (Fig.  690).  The  posterior  branch  runs 
horizontally  backward  across  the  squamous  plate  of  the  temporal  bone, 
and  crosses  the  temporo-parietal  suture  within  about  2  cm.  of  its  pos- 
terior end;  it  may  be  exposed  by  a  trephine  opening  about  2.5  cm. 
below  the  parietal  eminence. 

Concussion  and  Contusion  of  the  Brain. — The  brain  is  an  incom- 
pressible structure  suspended  within  a  bony  case  by  fibrous  partitions, 
chief  of  which  are  the  falx  and  tentorium;  it  is  held  relatively  immobile 
at  its  base  by  the  cranial  nerves,  bloodvessels,  and  processes  of  dura 
mater,  which  pass  through  the  base  of  the  skull.  It  is  surrounded  by 
a  small  amount  of  cerebrospinal  fluid,  which  is  in  greater  quantity 
toward  the  base,  especially  around  the  medulla;  and  its  ventricles, 
which  are  directly  continuous  with  the  subdural  spaces  (p.  599), 
are  filled  with  the  same  fluid.  A  blow  upon  the  head  causes  not  so 
much  a  vibration  or  tremefaction  of  the  brain  substance,  as  a  sudden 
displacement  of  the  brain  as  a  whole;  it  is  flung,  as  it  were,  against 
the  opposite  side  of  the  skull,  and  usually  it  is  contused  most  at  the 
point  of  impact,  or  the  polar  point,  or  at  the  base,  where  the  greatest 
strain  comes.  The  cerebellum  is  relatively  little  affected,  because 
of  its  protected  position  beneath  the  tentorium,  because  it  floats 
on  a  greater  amount  of  cerebrospinal  fluid,  and  because  of  the  possi- 
bility of  downward  displacement  by  crowding  the  medulla  into  the 
foramen  magnum.  Some  blows  on  the  head,  severe  enough  to  cause 
symptoms,  produce  symptoms  which  are  so  momentary  and  fleeting 
that  it  always  has  been  difficult  to  believe  that  they  were  attended 
by  structural  change.  And  until  modern  methods  of  histological 
study  were  developed,  it  happened  not  rarely  that  postmortem 
examination  failed  to  disclose  any  lesion  in  the  brains  of  those  who 
had  actually  died  with  symptoms  due  to  "concussion."  But  it  has 
come  to  be  recognized,  largely  through  the  investigations  of  Sir 
Prescott  Hewett  (1870),  that  the  condition  of  these  brains  is  not  one 
of  "concussion,"  as  was  formerly  taught,  but  is  the  result  of  con- 
cussion, and  is  characterized  by  contusion,  compression,  extravasation, 
laceration,  or  inflammation  in  varying  degrees.  Of  course,  it  cannot 
be  asserted  categorically  that  histological  changes  always  are  present 
in  patients  w^ho  recover  at  once  from  the  symptoms  of  concussion, 
because  there  is  no  opportunity  of  submitting  their  tissues  to  micro- 
scopical examination  at  the  time  of  injury;  but  the  belief  is  quite 
general,  and  I  believe  quite  justified,  that  even  when  the  symptoms 
produced  are  the  most  insignificant,  definite  lesions  exist,  and  that 
these  vary  from  temporary  arrest  of  cell-action,  with  capillary  stasis, 
or  the  slightest  grades  of  contusion,  with  punctate  hemorrhages, 
to  distinct  laceration,  ecchymosis,  exudation,  and  edema  of  the 
brain  and  pia-arachnoid. 


CONCUSSION  AND  CONTUSION  OF   THE  BRAIN  615 

Symptoms. — As  in  all  cases  of  injury,  some  degree  of  shock  is 
present,  and  it  often  is  difficult  to  distinguish  the  symptoms  of  this 
condition  from  those  due  to  concussion  of  the  brain.  After  a  blow 
on  the  head  only  such  symptoms  as  dizziness,  or  disturbances  of 
vision  (sparks,  specks,  etc.),  may  be  observed.  In  more  marked 
cases  there  is  momentary  loss  of  consciousness,  the  patient  falling 
as  one  dead;  or,  when  striking  the  head  in  a  fall,  lying  motionless 
for  a  few  seconds,  and  then  regaining  consciousness  and  rising  to  his 
feet  before  assistance  can  reach  him.  In  typical  cases,  two  distinct 
stages  may  be  recognized:1  (1)  The  patient  at  first  lies  motionless, 
senseless,  nearly  pulseless,  pale  and  cold,  breathing  feebly  but  natur- 
ally; the  pupils  dilated  or  contracted,  fixed  or  acting  freely;  perhaps 
with  involuntary  discharge  of  feces  and  urine.  He  will  swallow  if 
food  is  put  into  his  mouth.  From  this  first  stage,  which  may  last 
many  days,  the  patient  may  recover  without  further  trouble,  or  he 
may  gradually  sink  and  die  without  reaction;  or  the  first  stage  may 
last  a  few  moments  only,  the  patient  having  passed  into  the  second 
stage  before  the  surgeon  sees  him.  The  disappearance  of  the  first 
stage,  whether  by  passing  into  the  second  or  by  direct  recovery, 
commonly  is  marked  by  vomiting.  (2)  In  the  second  stage  the  patient 
is  no  longer  unconscious,  though  much  indisposed  to  speak  or  pay 
attention  to  surrounding  objects.  If  roused  by  a  question,  he  will 
answer,  but  peevishly  or  angrily,  turning  away  as  if  displeased  at 
the  interruption.  His  posture  is  peculiar:  he  lies  habitually  on  his 
side,  curled  up,  with  all  his  joints  more  or  less  flexed,  and  if  a  limb 
is  touched  he  draws  it  away  with  an  air  of  annoyance.  The  eyelids 
are  kept  firmly  closed.  The  pulse,  at  first  slow  and  weak,  gradually 
becomes  more  frequent  and  stronger;  the  breathing  is  easier,  and  the 
surface  regains  its  natural  warmth  and  color.  This  stage  gradually 
subsides,  after  several  hours  or  days,  and  as  the  patient  regains 
ability  and  willingness  to  communicate  with  those  around  him, 
he  complains  almost  invariably  of  severe  headache.  If  the  cerebral 
lesions  have  been  marked,  they  may  leave  the  patient  with  his  mental 
faculties  permanently  impaired;  usually,  however,  in  such  an  event, 
the  earlier  symptoms  will  have  been  those  of  compression  of  the 
brain  rather  than  those  recognized  as  due  to  concussion. 

Treatment. — The  patient  should  be  laid  horizontal,  with  the  head 
slightly  elevated,  in  a  darkened  room;  and  throughout  his  illness 
he  should  be  protected  from  all  noise.  During  the  first  stage,  stimu- 
lation for  shock  may  be  necessary.  So  soon  as  shock  is  recovered 
from,  the  bowels  should  be  evacuated,  the  urine  drawn  if  necessary; 
and  moderate  amounts  of  liquid  nourishment  should  be  administered. 
During  the  second  stage,  cold  should  be  applied  to  the  head,  while 
restoration  of  cerebration  may  be  hastened  by  the  administration 
of  calomel,  0.010  gramme  every  hour  for  six  doses,  for  its  "antici- 
patory antiplastic  effect"  (p.  606);  and  this  may  be  continued  every 

1  This  description  is  copied,  almost  verbatim,  from  the  Principles  and  Practice 
of  Surgery  of  John  Ashhurst,  Jr. 


61G  SURGERY  OF  THE  HEAD 

third  or  fourth  hour  for  several  days,  or  until  the  patient  is  clear  in 
his  head.  Should  restlessness  or  delirium  supervene,  it  is  well  to 
administer,  with  each  dose  of  calomel,  0.15  to  0.20  gramme  of  Dover's 
powder.  The  use  of  the  mind,  in  conversation,  reading,  etc.,  should 
be  resumed  very  gradually,  and  convalescence  should  be  prolonged, 
the  patient  living  by  rule  for  many  months  after  apparent  recovery, 
and  remaining  under  surgical  observation  until  by  the  lapse  of  time 
the  absence  of  complications  from  unrecognized  cerebral  lesions  is 
assured.  Examination  of  the  eye-grounds  and  the  visual  fields  will 
aid  in  excluding  serious  organic  changes. 

Compression  of  the  Brain. — As  already  stated,  the  brain  is  an 
incompressible  structure;  its  bulk  can  be  reduced  only  by  loss  of 
its  fluid  constituents;  if  compressed  in  one  direction  it  must  expand 
in  another.  Experimental  compression  of  the  brain  produces  first 
a  stasis  in  the  smaller  venous  channels;  the  longitudinal  sinus  col- 
lapses; the  blood  cannot  escape  from  the  skull.  If  pressure  increases 
the  arterioles  may  be  affected.  Normally  changes  in  intracranial 
vascular  pressure  are  compensated  for  by  the  ebb  and  flow  of  the 
cerebrospinal  fluid.  This  drains  away  into  the  veins,  and  these 
in  turn  empty  mostly  into  the  longitudinal  sinus  and  certain  emissary 
veins  through  the  diploe.  Increase  in  vascular  pressure  from  the  arte- 
rial side  is  easily  and  rapidly  compensated  for  by  venous  absorption 
of  cerebrospinal  fluid;  and  obstruction  to  the  venous  outflow  (often 
seen  in  cases  of  cervical  or  thoracic  neoplasms)  does  not  prove  inju- 
rious so  long  as  the  collateral  diploic  veins  are  open,  or  so  long  as  the 
cerebrospinal  fluid  can  pass  into  the  spinal  canal  and  escape  into  the 
venous  circulation  by  that  channel.  But  if  the  pressure  on  the  venous 
side  becomes  so  great  as  to  dam  the  blood  back  into  the  capillaries, 
these  side  escapes  become  blocked,  the  brain  may  be  forced  down 
until  the  medulla  chokes  off  the  outlet  for  cerebrospinal  fluid  through 
the  foramen  magnum,  and  symptoms  of  "compression"  appear. 
It  was  shown  experimentally  by  Althann,  in  1871,  and  since  his 
time  by  numerous  other  investigators,  that  "the  effect  of  space 
diminution  in  the  skull  was  identical  with  that  of  any  other  process 
which  hindered  cranial  circulation"  (Archibald,  1908);  so  that,  as 
pointed  out  by  von  Bergmann  (1880),  the  symptoms  of  "compression" 
are  due  not  to  actual  compression  of  nerve  elements,  but  to  cerebral 
anemia. 

The  maintenance  of  life  depends  on  the  functioning  of  the  chief 
medullary  centers,  vasomotor,  vagus,  and  respiratory;  and  it  is  to 
interference  with  the  circulation  of  these  centers  that  the  most  strik- 
ing symptoms  of  cerebral  compression  are  due.  Localized  compression 
produces  the  so-called  focal  symptoms,  i.  e.,  paralysis;  while  general- 
ized compression,  which  may  develop  independently  of,  or  may 
succeed,  local  compression,  is  particularly  characterized  by  bulbar 
symptoms:  interference  with  the  centers  already  named;  but  in 
generalized  compression  there  also  usually  is  unconsciousness,  from 
cortical  compression. 


COMPRESSION  OF  THE  BRAIN  617 

So  soon  as  anemia  affects  the  medulla,  the  vasomotor  center  is 
stimulated,  blood-pressure  is  raised  higher  than  intracranial  (extra- 
vascular)  pressure,  blood  again  reaches  the  medulla,  and  life  is  pro- 
longed, at  least  temporarily  (von  Schulten,  1885).  But  the  stimulus 
of  anemia  then  being  removed,  blood-pressure  sinks  somewhat,  as 
intracranial  pressure  continues  to  increase,  and  anemia  of  the  medulla 
again  occurs;  whence  renewed  stimulation  of  the  vasomotor  center, 
a  further  rise  in  blood  pressure,  and  again  a  temporary  relief  of  the 
medullary  anemia.  (Hushing  (1902,  1903)  followed  these  successive 
periods  of  anemia  and  return  of  circulation  by  observation  of  the 
cerebral  cortex  of  monkeys  through  a  trephine  opening;  and  his 
experiments  justify  the  conclusion  that  similar  changes  occur  in  the 
medulla. 

This  alternate  stimulation  and  depression  of  the  medullary  centers 
explains  the  more  or  less  periodic  phases  observed  in  the  blood- 
pressure  and  respiration  curves  obtained  from  such  patients.  They 
are  known  as  Traube-Hering  waves.  The  respiratory  phases  closely 
resemble  the  Cheyne-Stokes  type,  the  stage  of  apnea  occurring  when 
the  respiratory  center  is  deprived  of  blood,  and  the  hyperpnea  develop- 
ing when  circulation  is  restored  by  increase  in  blood-pressure.  This 
"life  and  death  struggle,"  as  von  Schulten  termed  it,  may  continue 
until  blood-pressure  reaches  enormous  heights;  Cushing  raised  it 
experimentally  to  290  mm.  Hg.;  but  unless  intracranial  pressure  is 
relieved,  the  medullary  centers  in  time  will  cease  to  react,  and 
sudden  fall  of  blood-pressure  will  occur,  followed  by  death.  "Death 
probably  always  occurs  from  primary  failure  of  the  vasomotor  center, 
rather  than  from  that  of  the  respiratory,  as  has  been  asserted  by 
some.  The  vasomotor  center  holds  the  key  to  the  position.  Its 
defeat  involves  that  of  the  respiratory  and  vagus  centers;  and  with 
their  defeat  the  whole  army  is  devoted  to  slaughter."  (Archibald, 
1908.) 

Causes. — Anything  which  increases  intracranial  pressure  may 
cause  symptoms  of  compression  of  the  brain.  This  includes:  (1) 
Foreign  bodies  driven  against  or  into  the  brain  (bone  fragments, 
bullets,  etc.);  (2)  hemorrhage,  subcranial,  subdural,  or  intracerebral; 
(3)  products  of  inflammation  (serous  effusion,  lymph,  pus);  (4) 
tumors  of  the  brain;  (5)  acquired  internal  hydrocephalus,  etc. 

Symptoms. — Very  slowly  induced  compression  may  not  produce 
symptoms  for  a  long  period;  and  even  in  cases  of  rapid  compression 
there  often  is  a  "stage  of  compensation"  from  rise  in  blood-pressure, 
during  which  no  symptoms  may  be  observed.  During  the  stage  of 
manifest  compression  two  periods  may  be  recognized:  (1)  Early 
symptoms:  There  is  irritation  of  the  cortical  and  medullary  centers, 
due  to  venous  stagnation;  slight  quickening  of  respiration,  and  rise 
in  blood-pressure;  headache,  dizziness,  restlessness,  roaring  in  the 
ears,  disturbed  sleep;  moaning  and  groaning;  and  at  times  delirium. 
Sometimes  circulatory  changes  in  the  fundus  oculi  can  be  detected, 
but  these  disappear  in  a  few  hours.  (2)  Late  symptoms:   The  gradual 


618  SURGERY  OF  THE  HEAD 

increase  in  the  compressing  force  finally  overcomes  the  blood-pressure, 
and  cerebral  anemia  results.  This  stimulates  the  vasomotor  center 
which  raises  blood-pressure  yet  higher  by  causing  peripheral  capillary 
constriction,  especially  in  the  splanchnic  area.  The  patient  lies 
somnolent,  stuporous,  even  comatose;  with  slow,  full,  bounding 
pulse ;  there  is  labored  respiration,  which  in  the  last  stages  approaches 
the  Cheyne-Stokes  type;  the  cheeks  are  passively  puffed  out  at  each 
expiration  ("smoking  his  pipe,"  the  French  call  it);  the  pupils  react 
sluggishly  or  not  at  all.  The  more  dilated  pupil  usually  is  on  the  side 
of  greatest  compression.  Sometimes  the  patient  can  be  partially 
roused  from  his  coma  by  pressure  on  the  supraorbital  nerve;  then 
slight  convulsive  movements  of  the  extremities  may  occur,  and  hemi- 
plegia, or  localized  paralysis  may  become  evident.  Irregularity  of 
the  respiration  is  one  of  the  earliest  and  surest  signs  of  approaching 
exhaustion  of  the  medullary  centers;  and  unless  blood-pressure  can 
be  measured  periodically  by  the  manometer,  respiration  is  a  more 
reliable  guide  as  to  prognosis  than  the  quality  of  the  pulse;  for  the 
"vagus  pulse,"  slow,  regular,  and  strong,  continues  practically 
unchanged  until  very  near  the  fatal  ending. 

Diagnosis. — If  the  early  symptoms  of  the  stage  of  manifest  com- 
pression were  borne  in  mind,  the  condition  often  could  be  diagnosed 
and  measures  for  relief  instituted,  before  the  later  stage,  complicated 
by  unconsciousness,  is  reached.  When  an  unconscious  patient  is 
examined,  the  existence  of  an  adequate  cause  for  cerebral  compres- 
sion always  should  be  excluded  before  dismissing  this  as  the  cause 
of  the  symptoms.  Many  a  patient  suffering  from  cerebral  compression 
has  been  sent  away  from  accident  wards  as  "drunk,"  when  a  very 
little  time  spent  in  examination  would  have  detected  focal  symptoms 
(pupillary,  facial,  or  lingual  paralysis;  monoplegia,  hemiplegia,  etc.); 
while  bulbar  symptoms  probably  could  have  been  discovered  if  they 
had  been  specifically  looked  for.  In  any  case  of  doubt,  keep  the 
patient  under  observation;  if  the  cause  of  symptoms  is  compression, 
this  soon  will  become  evident. 

Prognosis. — This  depends  very  largely  upon  the  cause  of  the  com- 
pression, and  the  time  at  which  treatment  is  instituted.  In  many 
cases  of  brain  tumor,  for  instance,  it  may  be  impossible  to  remove 
the  cause  of  compression,  so  that  cure  is  out  of  the  question;  but 
symptoms  may  be  relieved  and  life  prolonged  by  removing  the  counter- 
pressure  caused  by  the  skull.  But  even  in  cases  where  the  cause  of 
compression  can  be  removed,  treatment  may  not  be  instituted  until 
the  last  stages  of  compression,  and  the  medullary  centers  may  not 
recover;  or  even  though  they  recover,  the  focal  compression  may  have 
done  so  much  damage  to  the  cerebrum  as  to  impair  the  patient's 
mental  or  physical  ability  throughout  life. 

Treatment. — From  what  has  been  said  above  it  is  very  evident 
that  the  two  main  indications  are  to  maintain  blood-pressure  at  a 
higher  point  than  intracranial  (extravascular)  pressure,  and  to  relieve 


COMPRESSION  OF  THE  BRAIN  619 

the  compression  by  surgical  means.  The  full,  bounding  pulse,  the 
singing  in  the  ears,  etc.,  of  the  early  stages,  do  not  by  any  means 
indicate  that  the  patient  should  be  bled,  or  that  aconite  should  be 
administered;  they  are  an  index  of  his  compensatory  powers  and 
all  that  will  save  his  life  is  to  keep  his  blood-pressure  high,  and  to 
relieve  the  intracranial  pressure  as  quickly  as  possible.  Theoretically 
the  latter  point  may  be  gained  by  lumbar  puncture  of  the  subdural 
space  of  the  cord;  but  draining  away  cerebrospinal  fluid,  by  removing 
the  brain's  support  from  below,  may  serve  only  to  allow  the  super- 
incumbent pressure  to  force  the  medulla  down  into  the  foramen 
magnum,  thus  strangulating  it  and  causing  instant  death.  The  most 
imperative  indication  is  to  "decompress"  the  brain  by  removing 
some  of  the  overlying  cranium,  on  one  or  both  sides.  This  may  be 
done  by  the  trephine,  the  opening  being  enlarged  by  rongeur  forceps, 
or  a  bone-flap  may  be  raised  (p.  632).  At  the  same  time  that  decom- 
pression is  done,  the  cause  of  compression,  whenever  possible,  should 
be  removed.  The  site  of  the  cranial  opening  depends  on  the  cause 
of  compression  and  on  the  existence  of  focal  symptoms;  when  not 
contraindicated  the  subtemporal  operation  of  Cushing  (p.  634)  is 
very  satisfactory. 

In  the  most  advanced  stages  of  cerebral  compression  emergency 
measures  are  necessary  to  raise  the  blood-pressure  until  operation 
can  be  undertaken;  these  are  such  methods  as  artificial  respiration, 
lowering  the  patient's  head,  bandaging  his  extremities,  compression 
of  the  abdomen,  and  the  administration  of  strychnin,  adrenalin,  etc. 
After  decompression  it  should  be  remembered  that  the  stimulating 
effect  of  recurring  anemia  upon  the  vasomotor  center  is  lost;  and 
if  this  center  shows  signs  of  exhaustion,  it  must  be  stimulated  by 
strychnin,  or  repeated  doses  of  adrenalin. 

Subcranial  or  Extradural  Hemorrhage  may  be  due  to  bleeding 
from  the  diploe  or  cranial  sinuses,  in  cases  of  fracture  of  the  skull, 
but  in  the  vast  majority  of  cases  it  is  due  to  rupture  of  the  middle 
meningeal  artery.  Middle  meningeal  hemorrhage  may  occur  with  or 
without  fracture  of  the  skull,  and  upon  the  side  of  injury  or  on  the 
opposite  side  (from  "contre-coup").  The  anterior  branch  of  the 
artery  is  most  often  ruptured,  usually  near  the  pterion,  where  it 
passes  through  a  bony  groove  or  canal;  but  it  may  be  torn  off  at  its 
exit  from  the  foramen  spinosum  (by  concussion,  or  by  a  bursting 
fracture),  or  lacerated  by  bone  fragments  at  other  parts  of  its  course. 
The  bleeding  which  results  slowly  separates  the  dura  from  the  cranium, 
and  the  resulting  clot  may  spread  over  an  entire  hemisphere  (Fig.  691). 

Diagnosis. — The  usual  history  is  that  after  an  injury  to  the  head 
the  patient  experiences  momentary  symptoms  of  concussion,  then 
recovers  more  or  less  completely;  but  some  hours  or  even  days  later 
signs  of  compression  appear,  sometimes  gradually,  sometimes  with 
alarming  suddenness.  What  is  particularly  characteristic  is  the  so- 
called  "free  interval,"  between  the  injury,  when  rupture  occurs,  and 


020 


SURGERY  OF  THE  HEAD 


the  time  when  the  accumulating  clot  brings  on  symptoms  of  com- 
pression. 

Treatment. — The  treatment  consists  in  exposing  the  artery  (anterior 
or  posterior  branch,  according  to  the  site  of  injury  and  the  symptoms, 

p.  613),  removing  the  clot,  tracing 
the  bleeding  to  its  source,  and  ligat- 
ing  the  artery  by  passing  a  fine 
suture  around  it  by  means  of  a 
round-pointed  needle.  If  all  focal 
signs  are  absent,  and  no  cause  for 
compression  is  found  on  the  side  of 
the  skull  first  opened,  it  is  justifiable 
to  open  the  other  side,  as  rupture 
may  occur  from  counter-stroke. 

Intradural  Hemorrhage. — Bleed- 
ing into  the  meshes  of  the  pia- 
arachnoid,  which  is  much  more 
frequent  than  the  extradural  form, 
almost  invariably  is  of  traumatic 
origin,  venous  in  character,  and 
complicated  by  extensive  cranial 
and  cerebral  injury  (Fig.  692). 
Usually  the  blood  is  widely  diffused, 
and  the  fluid  removed  by  lumbar 
puncture  may  be  blood-tinged. 
The  symptoms  are  those  of  cerebral 
compression;  "it  is  safe  to  say,"  writes  Cushing,  "that  in  any  serious 
cranial  injury  in  which  unconsciousness  has  been  present  from  the 


Fig.  691.  —  Subcranial  hemorrhage 
from  rupture  of  the  posterior  branch  of 
the  middle  meningeal  artery.  No  frac- 
ture of  the  cranium.  Man,  aged  fifty- 
one  years,  was  found  lying  on  the  street, 
unconscious.  Taken  to  police  station. 
Operation  about  forty  hours  after  in- 
jury. Blood-pressure  fell  from  170 
mm.  before  operation  to  110  mm.  a  few 
hours  later.  Recovery.  (See  Fig.  703) 
Episcopal  Hospital. 


Fig.  692. — Intradural  hemorrhage.  A  boy  of  five  years  had  a  large  flap  of  scalp  torn 
loose.  Parietal  bone  bent  inward,  but  no  fracture.  Operation  three  hours  later  (for 
continued  unconsciousness  and  left  hemiplegia)  showed  extensive  intradural  hemor- 
rhage, the  brain  being  4  cm.  distant  from  the  dura.  After  removal  of  compression  respira- 
tion improved,  but  death  occurred  in  a  few  hours.    Episcopal  Hospital. 

first,   subdural   bleeding  is  taking  place,   either   from  the   fracture 
itself  or  from  some  laceration  of  the  brain."      Treatment  consists  in 


SINUS  THROMBOSIS  621 

decompression  if  symptoms  of  compression  continue  for  more  than  a 
few  hours  or  are  well  marked  at  first.  Seldom  is  it  possible  to  find 
any  distinct  bleeding  point,  but  exposure  to  the  air,  or  gentle  irriga- 
tion with  very  hot  saline,  may  be  sufficient  to  arrest  the  hemorrhage. 
Drainage  is  provided  by  strips  of  rubber  tissue.  The  operation, 
unless  another  opening  is  indicated  by  cranial  injury  or  focal  symp- 
toms, should  be  by  Cusbing's  subtemporal  route  (p.  634)  which  gives 
ready  access  to  the  base  of  the  brain  whence  the  bleeding  usually  arises. 

Intracranial  Hemorrhages  in  the  Newborn. — These  occur  usually 
from  a  rupture  of  a  vein  in  the  pia-arachnoid,  near  the  longitudinal 
sinus,  as  the  result  of  trauma  during  birth.  The  diagnosis  is  not 
always  easy,  at  least  until  signs  of  compression  of  the  brain  appear; 
lumbar  puncture  may  show  bloody  cerebrospinal  fluid;  and  cerebral 
irritability  and  irregularity  of  respiration  are  suggestive.  The  prog- 
nosis is  bad;  nearly  80  per  cent,  die  from  cerebral  compression  within 
a  few  days;  while  of  those  that  recover  most  are  mentally  deficient 
or  afflicted  with  spastic  paralysis  (p.  572),  athetosis,  nystagmus, 
etc.  Treatment:  Operative  relief,  proposed  by  Keen  in  1901,  was 
first  employed  in  1904  by  Cushing,  who  reported  (1908)  nine 
operations,  with  four  recoveries.  A  large  osteoplastic  flap,  which 
can  be  cut  out  with  strong  scissors,  is  raised,  the  dura  is  opened,  the 
clots  removed  by  gentle  irrigation,  and  the  wound  closed  without 
drainage. 

Intracerebral  Hemorrhage  occurs  chiefly  as  the  result  of  vascular 
disease  (ordinary  "apoplexy"),  or  from  degenerative  changes  in 
brain  tumors.  Wounds  are  occasionally  causes  of  localized  cortical 
hemorrhage.  The  suggestion  by  Leonard  Hill  (1896)  that  surgery 
by  effecting  decompression,  or  even  by  evacuation  of  the  clot,  might 
be  of  use  in  these  cases,  was  acted  upon  with  success  by  Borsuk  and 
Wizel  (1897)  in  a  traumatic  case.  Cushing  (1908)  operated  on 
four  cases  of  spontaneous  hemorrhage,  one  operation  (subtemporal 
decompression  and  evacuation  of  the  clot)  being  successful.  Under 
expectant  treatment  the  mortality  is  nearly  90  per  cent.,  in  these 
cases  of  acute  severe  apoplexy,  in  which  alone  is  operation  to  be 
considered. 

Sinus  Thrombosis. — This  arises,  in  the  vast  majority  of  cases,  by 
extension  of  septic  inflammation  from  the  air  sinuses  of  the  skull, 
especially  the  mastoid  cells.  Pyogenic  inflammation  of  the  scalp  or 
erysipelas  are  rare  causes,  the  infection  spreading  along  the  diploic 
emissary  veins.  The  diagnosis  depends  on  recognizing  a  focus  from 
which  septic  inflammation  may  be  derived,  on  local  signs  such  as 
edema  of  the  overlying  scalp,  and  distention  of  its  veins,  together 
with  evidences  of  constitutional  sepsis,  and  perhaps  cerebral  com- 
pression. The  longitudinal  sinus  may  be  thrombosed  from  frontal, 
ethmoidal,  or  sphenoidal  sinusitis,  or  rarely  from  erysipelas  of  the 
scalp,  etc.  Thrombosis  of  the  cavernous  sinus,  which  is  very  rare, 
may  arise  from  extension  of  inflammation  along  the  facial  and  angular 
veins  (carbuncle  of  upper  lip,  etc.),  or  along  the  petrosal  sinuses 


622  SURGERY  OF   THE   HEM) 

(from  the  sigmoid  sinus),  and  is  particularly  characterized  by  the 
resulting  exophthalmos. 

The  lateral  sinus,  especially  its  sigmoid  portion,  is  that  which  is 
involved  in  by  far  the  largest  number  of  cases,  and  almost  always 
as  the  result  of  middle-ear  disease,  the  infection  coming  along  the 
emissary  veins  or  directly  invading  the  sinus  wall  after  destruction 
of  the  intervening  bone.  The  symptoms  are  those  of  the  preexisting 
disease  (mastoiditis),  of  sepsis  (repeated  chills,  sweating,  hectic 
temperature),  and  cerebral  irritation  or  compression  (rare);  but 
such  symptoms  often  do  not  appear  until  the  sinus  thrombosis  has 
been  in  existence  for  some  days,  and  may  indicate  a  softening  of  the 
clot  and  dissemination  of  emboli.  Naturally  the  lungs  are  most 
often  attacked  in  this  way.  Thrombosis  is  prone  to  extend  to  the 
internal  jugular  vein,  and  often  this  can  be  felt  as  a  tender  cord  in  the 
neck.  The  head  may  be  tilted  to  the  affected  side.  In  meningitis, 
which  is  much  commoner  in  infants  than  adults  as  a  result  of  middle- 
ear  disease,  cerebral  symptoms  (vertigo,  vomiting,  hebetude,  delirium) 
are  more  marked,  there  is  retraction  of  the  neck  and  paralysis  of  the 
ocular  muscles,  with  choked  disk;  fever  is  higher  and  more  regular; 
Kernig's  sign  is  present;  and  lumbar  puncture  shows  turbid  cerebro- 
spinal fluid,  from  which  organisms  may  be  recovered.  In  brain 
abscess  cerebral  symptoms,  without  those  of  meningitis,  predominate; 
temperature  is  subnormal;  there  is  evidence  of  cerebral  compression; 
and  emaciation  is  rapid.  In  neither  meningitis  nor  in  uncomplicated 
cases  of  brain  abscess  is  there  thrombosis  of  the  internal  jugular  vein. 

Treatment. — The  first  step  is  to  clear  out  the  mastoid,  and  this 
merely  preliminary  measure  should  not  be  done  with  too  great  delib- 
eration (see  Chapter  XIX).  The  shell  of  bone  which  overlies  the 
sigmoid  sinus  is  then  removed  by  gouge  or  burr,  and  the  sinus  well 
exposed;  plenty  of  room  should  be  gained  by  use  of  the  rongeur.  The 
sinus  is  next  incised:  if  bleeding  occurs  the  sinus  is  compressed  first 
on  the  torcular  side;  and,  if  it  continues,  also  on  the  jugular  side  of 
the  incision.  Persistence  in  bleeding,  when  pressure  is  made  at  both 
these  points,  indicates  a  return  flow  from  the  mastoid  emissary  or 
superior  petrosal  sinus.  These  should  be  separately  tested.  If  the 
petrosal  is  not  thrombosed  it  is  probable  that  the  entire  system  is 
healthy.  //  no  bleeding  occurs  when  the  sinus  is  opened,  it  should 
be  slit  up  toward  the  torcula  until  a  return  flow  is  obtained;  this  is 
controlled  by  packing;  the  clot  is  then  removed  as  far  as  the  original 
incision,  and,  after  temporary  pressure  has  been  made  on  both  jugulars 
in  the  neck,  a  similar  procedure  is  carried  out  at  the  bulbar  end  of  the 
sinus.  If  no  return  flow  can  be  obtained  from  this  end  of  the  sinus, 
it  is  a  sign  that  the  thrombus  extends  into  the  jugular,  and  resection 
of  this  vein  should  be  done.  It  is  to  be  performed  as  a  primary  oper- 
ation, before  exposing  the  sinus,  when  a  diagnosis  of  jugular  thrombosis 
is  made  in  advance.  Resection  of  the  Internal  Jugular  Vein:  The 
vein  is  exposed  and  doubly  ligated  low  in  the  neck;  it  is  divided 
between  these  ligatures  and  dissected  upward,  clamping  and  tying 


LEPTOMENINGITIS  623 

each  branch  encountered.  Thrombosed  branches  should  be  excised. 
When  the  vein  has  been  traced  up  as  far  as  possible,  it  is  ligated  and 
cut  across.  The  neck  wound  is  tamponed  with  gauze  and  not  closely 
sutured.  If  the  jugular  vein  is  too  densely  adherent  to  be  removed 
safely,  it  should  be  slit  open,  and  the  wound  packed  with  gauze. 
The  general  mortality  of  thrombosis  of  the  lateral  sinus  is  about  25 
per  cent. 

Meningitis. — External  Pachymeningitis,  usually  purulent  and  local- 
ized {subcranial  abscess),  affects  the  external  layer  of  the  dura,  and 
may  result  from  osteomyelitis  of  the  cranium  (p.  611)  with  or 
without  fracture  of  the  skull,  or  from  neighboring  sinus  thrombosis. 
Treatment  consists  in  removal  of  the  overlying  bone,  with  drainage. 

External  hemorrhagic  pachymeningitis,  usually  the  result  of  trauma 
(an  organizing  clot  resulting  from  middle  meningeal  hemorrhage), 
gives  symptoms  of  cerebral  irritation  more  or  less  confined  to  the 
area  immediately  affected.  The  best  treatment  is  thorough  extirpation 
of  the  diseased  tissues. 

Internal  Pachymeningitis  is  a  rare  disease,  of  subacute  or  chronic 
character,  in  which  membranous  lymph,  easily  detachable,  is  deposited 
on  the  inner  layer  of  the  dura.  It  is  microbic  in  origin,  occurs  some- 
times in  general  infections  (typhoid  fever,  pneumonia),  and  some- 
times is  hemorrhagic  in  type.  The  symptoms  are  not  very  character- 
istic, being  those  of  slowly  increasing  cerebral  irritation  or  compres- 
sion; and  the  diagnosis  is  difficult.  Treatment:  operation,  comprising 
removal  of  the  false  membrane  or  hemorrhagic  exudate,  offers  the 
only  hope  of  cure  or  prevention  of  insanity  (Munro,  1902). 

Leptomeningitis. — Inflammation  affecting  the  pia-arachnoid  may 
be  due  to  various  bacteria;  the  form  known  as  epidemic  cerebrospinal 
meningitis,  caused  by  the  Diplococcus  intracellulars,  is  a  specific 
contagious  disease,  usually  coming  under  the  physician's  care.  Early 
intraspinal  use  of  Flexner's  serum  (1906)  is  most  important.  From  15 
to  30  c.c.  are  given,  according  to  the  age,  and  repeated  every  twenty- 
four  hours.  If  begun  promptly  enough,  four  injections  usually  suffice. 
The  ultimate  cause  of  death  is  purely  mechanical,  being  due  to  cerebral 
compression  from  acute  internal  hydrocephalus  (p.  599),  and  lumbar 
puncture,  used  for  diagnosis,  may  be  repeatedly  employed  with 
benefit,  even  when  no  serum  is  available  for  injection;  but  it  is  of 
no  therapeutic  value  when  hydrocephalus  supervenes;  the  only  remedy 
then  is  single  or  repeated  puncture  of  the  ventricles. 

Leptomeningitis  also  may  be  caused  by  ordinary  pyogenic  cocci, 
pneumococcus,  B.  tuberculosis,  etc.  Especially  in  tuberculous  menin- 
gitis, which  is  so  uniformly  fatal  under  medical  treatment,  it  seems 
as  if  almost  any  surgical  risk  were  justifiable;  and  if  repeated  lumbar 
puncture  proves  ineffectual,  puncture  of  the  ventricles  should  be  done 
(p.  600). 

Serous  or  Amicrobic  Meningitis  is  a  form  of  the  affection  in  which 
clear,  sterile  serous  fluid  collects  in  the  intradural  spaces  (Eichhorst, 
1887).     Some  cases  are  traumatic  in  origin,  but  most  are  regarded 


624  SURGERY  OF  THE  HEAD 

as  due  to  bacterial  infection  localized  elsewhere  in  the  body,  thus 
being  analogous,  as  pointed  out  by  Archibald  (1908),  to  the  sterile 
serous  effusion  of  pleurisy  secondary  to  subphrenic  abscess.  Some- 
times this  affection  complicates  sinus  thrombosis  or  mastoiditis. 

Diagnosis. — The  diagnosis  is  difficult,  the  serous  character  of  the 
effusion  being  discovered  first  at  operation  undertaken  to  relieve 
pressure  symptoms  thought  to  be  due  to  subcranial  or  intradural 
suppuration,  or  to  brain  abscess. 

Treatment. — In  traumatic  cases  lumbar  puncture  may  suffice  to 
evacuate  the  fluid;  in  others  craniotomy  should  be  done.  If  serous 
meningitis  is  found,  undue  persistence  should  not  be  exercised  in 
searching  for  a  brain  abscess  which  may  not  exist. 

Syphilis  of  the  Leptomeninges. — Practically  all  the  intracranial 
lesions  of  syphilis  arise  in  the  meninges  and  involve  the  brain  only 
secondarily,  by  pressure.  They  are  found  most  often  in  the  arachnoid 
tissues,  especially  in  the  frontal  region  and  at  the  base.  The  diagnosis 
from  cerebral  tumors  is  not  easy,  but  the  treatment  is  much  the 
same  (p.  030). 

Encephalitis  or  Cerebritis,  except  as  it  complicates  traumatic 
lesions,  concerns  surgeons  little,  unless  in  localized  form  (Brain 
Abscess).  There  is  an  epidemic  form,  analogous  to  acute  anterior 
poliomyelitis  known  as  lethargic  encephalitis;  should  patients  survive 
and  present  paralysis,  orthopedic  treatment  is  indicated. 

Brain  Abscess. — This  is  due  in  about  equal  proportions  to  trauma, 
especially  penetrating  and  punctured  wounds,  and  to  suppurative 
disease  of  the  mastoid  cells,  middle  ear,  or  other  air  sinuses  of  the 
cranium.  It  occurs  also  in  pyemia,  but  very  much  less  frequently. 
The  site  of  the  abscess  in  the  brain  depends  largely  on  the  focus  of 
infection.  Frontal  abscess  results  from  disease  of  the  frontal  sinuses, 
ethmoid  and  sphenoid  cells,  cavernous  sinus  thrombosis,  etc.  Middle- 
ear  disease  is  the  chief  cause  of  abscess  in  the  temporo-sphenoidal 
lobe;  while  cerebellar  abscess  usually  is  secondary  to  mastoid  disease 
or  lateral  sinus  thrombosis.  The  causative  condition  frequently 
has  been  in  existence  for  months  or  even  years,  before  brain  abscess 
develops.  The  cerebrum  is  affected  more  than  twice  as  often  as  the 
cerebellum.  The  abscess  almost  always  is  in  the  subcortical  area 
of  the  brain,  and  seldom  has  any  macroscopical  connection  with  the 
source  of  infection,  having  arisen  from  embolism  (rare),  or  by  pro- 
gressive thrombosis  of  minute  venous  channels.  Usually,  if  not 
invariably,  however,  there  exists  a  microscopic  connection  between 
the  source  of  infection  in  the  cranial  bones  and  the  abscess  cavity; 
the  abscess  has  been  compared  to  a  mushroom,  growing  by  a  stalk 
from  the  neighboring  carious  bone. 

Symptoms. — When  the  abscess  follows  middle-ear  disease,  which 
is  its  most  frequent  single  cause,  and  may  be  taken  as  the  type,  it  is 
usual  for  there  to  have  been  some  recent  exacerbation  of  the  chronic 
symptoms.  The  course  of  a  typical  case  is  well  sketched  by  Cushing : 
after  the  exacerbation  of  the  old  symptoms,  arise  those  of  the  initial 


BRAIN  ABSCESS 


625 


stage  of  brain  abscess  (headache,  nausea,  chilliness,  and  fever)  (Fig. 
693) ;  these  may  subside,  but  rarely  disappear  entirely,  for  a  period  of 
a  week  or  ten  days  {latent  stage) ;  then,  with  more  or  less  sudden  cessa- 
tion of  discharge  from  the  ear,  symptoms  of  intracranial  sepsis  and 
pressure  become  evident  (persistent  headache,  mental  hebetude,  vom- 


Fig.  693. — Cerebral  abscess  from  mid- 
dle-ear disease;  initial  stage:  headache, 
nausea,  chilliness,  and  fever.  (G. 
Laurens.) 


Fig.  694. — Cerebral  abscess  from 
middle-ear  disease;  manifest  stage:  per- 
sistent headache,  mental  hebetude,  and 
other  symptoms  of  compression.  (G. 
Laurens.) 


iting,  slow  pulse,  subnormal  temperature,  and  leukocytosis  (manifest 
stage)  (Fig.  694).  Usually  there  are  no  distinct  focal  symptoms,  other 
than  marked  tenderness  of  the  overlying  skull,  and  sometimes  facial 
paralysis.  Rapid  emaciation  is  a  very  significant  sign.  If  the  abscess 
is  in  the  cerebellum,  meningitis  may  be  simulated  (Fig.  695).  The 
distinction  between  abscess  and  tumor  of  the  brain  seldom  is  difficult 
(p.  628). 


Fig.  695. — Cerebellar  abscess  from  middle-ear  disease,  simulating  meningitis 
(retraction  of  the  head,  occipital  headache,  etc.).     (G.  Laurens.) 


Treatment. — The  abscess  must  be  drained  as  early  as  possible. 
Do  not  delay  overnight  if  you  suspect  an  abscess.  Some  surgeons 
prefer  to  do  a  tympano-mastoid  exenteration  first,  and  then  wait  a 
few  days,  to  see  if  the  symptoms  suggestive  of  brain  abscess  will 
subside;  but  if  an  abscess  is  present,  any  delay  is  dangerous.  Many 
40 


626  SURGERY  OF  THE  HEAD 

operators  prefer  to  open  the  intact  cranium  (Macewen,  1893)  over 
the  supposed  site  of  abscess,  and  to  proceed  to  exenteration  of  the 
tympano-mastoid  only  after  evacuating  the  abscess.  For  abscess 
in  the  temporo-sphenoidal  lobe  trephine  at  a  point  2.5  cm.  above  the 
suprameatal  spine.  The  cerebellum  is  exposed  by  trephining  below 
the  lateral  sinus  and  posterior  to  its  sigmoid  portion.  Most  aurists 
think  it  safer  to  approach  the  brain  abscess  through  the  middle 
ear  or  mastoid,  because  by  this  avenue  one  is  most  certain  to  cross  the 
meninges  where  adhesions  exist,  and  can  follow  on  to  the  abscess 
along  its  "  stalk."  When  the  cortex  is  exposed,  in  either  case,  measures 
should  be  taken  to  prevent  contamination  of  the  meninges,  unless 
the  diseased  area  is  isolated  already  by  adhesions.  The  brain  is 
then  explored  by  a  grooved  director,  and  when  pus  is  found  the 
overlying  cortex  is  incised  on  the  director,  sufficiently  to  secure 
drainage.  This  is  difficult  to  maintain,  as  the  semifluid  brain  tends 
to  block  the  tube.  A  glass  tube  should  be  used.  Should  damming 
up  of  pus  be  suspected,  the  wound  must  be  reopened.  Even  in  the 
hands  of  the  most  skilled  and  expert  surgeons,  operation  for  brain 
abscess  is  attended  by  a  mortality  of  about  50  per  cent.;  but  as  all 
patients  will  die,  and  quite  as  soon,  if  no  operation  is  done,  this  should 
not  deter  one  from  trying  to  save  even  moribund  patients. 

Brain  Tumor. — Any  growth  within  the  cranium,  whether  a  true 
neoplasm  or  an  infectious  granuloma,  is  considered  clinically 
"brain  tumor,"  because  productive  of  the  same  general  signs.  Tuber- 
culoma is  the  most  frequent  growth  in  childhood;  these  tumors  occur 
with  special  frequency  in  the  cerebellum,  and  often  are  multiple. 
Syphiloma  is  more  common  in  adults,  being  usually  a  meningeal 
growth  which  compresses  the  brain  secondarily.  These  two  types 
of  growth  form  a  larger  class  of  brain  tumors  than  do  the  true  neo- 
plasms. Of  the  latter,  the  most  frequent  are  endothelioma  and  glioma. 
The  former  grows  from  the  meninges,  usually  is  encapsulated  and 
easily  enucleated  from  the  cup-shaped  depression  it  produces  in  the 
surface  of  the  brain  (Fig.  696) ;  the  glioma,  on  the  other  hand,  usually  is 
an  infiltrating  growth  of  the  subcortical  area  (Fig.  697)  and  may  be  with 
difficulty  distinguishable  macroscopically  from  normal  brain  tissue. 
Sarcoma  which  is  less  usual,  grows  from  the  connective  tissue  of  the 
meninges,  frequently  invading  the  bone;  or  may  arise  in  the  cortex, 
whence  it  sometimes  can  be  shelled  out,  owing  to  peripheral  degenera- 
tive changes.  Often  it  is  multiple,  and  is  a  more  frequent  form  of 
metastatic  growth  than  carcinoma.  Fibroma  is  seldom  seen  except  in 
the  cerebellopontine  angle.  Cysts  occur  in  the  brain;  some  are  of  para- 
sitic origin  (echinococcus,  cysticercus),  others  are  the  result  of  hemor- 
rhages'into  the  brain  substance,  or  arise  as  degenerative  changes  in  a 
glioma.    The  latter  is  the  usual  cause  of  cerebellar  cysts. 

Symptoms. — Tumors  grow  in  the  brain  oftener  than  in  any  other 
part  of  the  body.  Hale  White  (1885)  estimated  that  a  tumor  is  found 
in  the  brain  in  one  among  every  59  autopsies.  They  may  exist  for 
years  and  cause  no  symptoms,  if  in  a  silent  region  or  if  of  very  slow 


BRAIN   TUMOR  627 

growth.  They  occur  mostly  between  the  ages  of  fifteen  and  fifty.  In 
old  age  and  infancy  they  are  rare.  It  is  usual  to  discuss  the  symp- 
toms of  brain  tumor  under  two  headings,  general  symptoms,  and 
localizing  symptoms. 


Fig.  696. — Endothelioma  of  the  left  hemisphere  of  the  brain  in  the 
post-central  region.     Episcopal  Hospital. 

General  Symptoms. — The  syndrome  of  brain  tumor  comprises  the 
three  cardinal  symptoms,  headache,  vomiting,  and  papilledema.  Headache 
at  first  is  intermittent,  but  when  constant,  and  especially  when  referred 
persistently  to  one  region,  which  is  tender  to  percussion  or  pressure, 
must  be  regarded  as  highly  significant;  probably  it  is  due,  as  pointed 
out  by  Cushing  (1908),  to  pressure  upon  or  distortion  of  the  falx 
or  tentorium,  as  the  brain  itself  is  insensitive.  The  vomiting,  perhaps 
due  to  irritation  of  the  pneumogastric  nerve,  is  projectile  in  character, 
may  occur  independently  of  meals,  and  be  unattended  by  nausea. 
Papilledema,  optic  neuritis,  or  choked  disk,  is  a  characteristic  change 


Fig.  697. — Glioma  of  the  left  hemisphere  of  the  brain  in  the 
pre-central  region.     Episcopal  Hospital. 

in  the  eye-grounds,  commonly  believed  to  be  due  to  damming  up  of 
the  cerebrospinal  fluid  in  the  sheath  of  the  optic  nerve,  as  the  result 
of  increased  intracranial  tension.  If  this  pressure  is  not  relieved, 
hemorrhages  may  occur  in  the  nerve  head  and  retina,  resulting  in 


628  SURGERY  OF   THE  HEAD 

permanent  blindness.  Usually  both  optic  nerves  are  affected,  but 
unequal  involvement  of  the  two  nerves  does  not  indicate  that  the 
compressing  lesion  is  on  the  side  where  papilledema  is  greatest, 
unless  only  one  nerve  is  appreciably  involved.  Papilledema  often 
is  more  marked  in  subtentorial  lesions  than  others.  The  importance 
of  examining  the  eye-grounds  in  all  suspected  cases  of  intracranial 
lesion  cannot  be  too  much  emphasized,  as  acuity  of  vision  may  persist 
even  when  papilledema  is  moderately  far  advanced.  On  the  other 
hand,  this  sign  may  be  entirely  absent  throughout  the  course  of 
the  disease.  Changes  in  the  color  fields,  detected  by  expert  ophthal- 
mological  examination,  may  be  one  of  the  earliest  of  the  general 
signs  of  brain  tumor.  No  bulbar  symptoms,  such  as  occur  in  com- 
pression of  the  brain  from  trauma,  are  observed  in  cases  of  brain 
tumor,  because  the  increase  in  pressure  is  so  very  gradual.  Occasion- 
ally a  brain  tumor,  previously  unsuspected,  makes  its  presence  known 
first  by  the  occurrence  of  a  hemorrhage  into  the  tumor,  the  symptoms 
resembling  those  of  ordinary  apoplexy;  and  in  a  young  adult  such  an 
occurrence  should  rouse  the  suspicion  of  a  brain  tumor. 

Localizing  Symptoms. — These  are  interpreted  through  anatomical 
knowledge  of  the  seat  of  the  cerebral  functions.  As  the  increase  in 
pressure  occurs  very  slowly,  it  is  the  ride  for  the  development  of  paralytic 
symptoms  to  be  delayed,  usually  being  preceded  by  irritative  symptoms 
(Jacksonian  epilepsy,  p.  636);  and  a  very  slowly  growing  tumor  in  a 
silent  region  of  the  brain  may  produce  no  localizing  symptoms  until 
by  encroachment  it  involves  the  nearest  physiologically  recognizable 
centre,  causing  "neighborhood"  as  distinguished  from  true  "focal" 
symptoms.  Thus  a  tumor  in  the  frontal  lobe  may  make  its  presence 
known  only  by  general  symptoms  (headache,  vomiting,  papilledema), 
until  so  large  as  to  interfere  with  the  motor  functions;  and  when 
paralysis  of  motion  at  last  occurs,  the  incautious  observer  may  jump 
to  the  conclusion  that  the  tumor  is  growing  in  the  motor  region; 
instead  of  recognizing  the  fact,  as  he  would  have  done  if  an  accurate 
history  of  the  progress  of  the  disease  had  been  obtained,  that  the 
growth  evidently  was  primary  elsewhere,  and  had  compressed  the 
motor  region  only  secondarily. 

Diagnosis. — This  involves  not  only  the  determination  whether  a 
tumor  exists  at  all,  but  also  the  recognition  of  the  kind  of  tumor 
present,  and  its  location. 

1.  Brain  tumor  may  be  closely  simulated  by  the  cerebral  symptoms 
of  chronic  nephritis;  the  urinary  changes  in  the  latter  condition  are 
the  chief  distinction,  but  as  a  brain  tumor  may  coexist,  the  patient 
should  be  watched  for  the  development  of  localizing  symptoms. 
Abscess  of  the  brain  usually  may  be  distinguished  from  brain  tumor 
by  the  history  of  trauma,  bone  disease,  etc.,  which  is  absent  in  the 
latter  affection;  as  well  as  by  the  more  acute  course  of  the  disease 
in  cases  of  brain  abscess.  Acquired  internal  hydrocephalus  (p.  599) 
usually  exists  as  a  complication  of  brain  tumor,  and  as  already  noted, 
this  condition,  rather  than  the  actual  bulk  of  the  tumor  may   be 


BRAIN   TUMOR  629 

responsible  for  the  symptoms  of  intracranial  pressure.  Increased 
pressure  of  the  cerebrospinal  fluid,  as  detected  by  a  manometer 
attached  to  the  lumbar  puncture  needle,  may  be  another  clue.  The 
normal  pressure  is  less  than  12  mm.  of  mercury,  and  readings  of  20 
mm.  or  higher  are  distinctly  pathological  (Kolmer,  1918).  Sometimes 
a  brain  tumor  may  be  detected  by  aid  of  a  skiagraph. 

2.  The  kind  of  tumor  is  very  difficult  and  usually  impossible  to 
determine.  The  existence  elsewhere  in  the  body  of  a  tuberculous 
process  naturally  would  suggest  a  tuberculoma  as  the  cause  of  the 
symptoms;  as  would  a  history  of  syphilis  or  evidence  of  past  or 
present  syphilitic  lesions  the  existence  of  a  syphiloma.  The  tuber- 
culin tests  and  the  Wasserman  reaction  are  also  available.  The  use 
of  antisyphilitic  remedies,  as  a  method  of  exclusion,  though  quite 
habitual,  should  not  be  persisted  in  for  more  than  six  weeks  (Horsley, 
1890),  unless  relief  of  symptoms  is  secured  sooner;  because,  in  the 
first  place,  few  intracranial  syphilomas  are  permanently  influenced 
by  medication,  and,  secondly,  other  forms  of  tumor  may  undergo 
temporary  regression  under  antisyphilitic  treatment,  only  to  cause 
renewed  symptoms  later.  Moreover,  it  is  quite  characteristic  of 
the  intracranial  lesions  of  syphilis  to  undergo  spontaneous  retro- 
gression and  recrudescence,  even  in  the  absence  of  treatment.  Lumbar 
puncture  may  aid  the  diagnosis  by  showing  the  constant  lymphocy- 
tosis so  characteristic  of  syphilis,  or  by  revealing  the  tuberculous 
nature  of  the  affection  by  appropriate  pathological  methods.  Noth- 
ing certain  can  be  said  of  the  diagnosis  of  glioma,  endothelioma, 
sarcoma,  etc. 

3.  The  Site  of  the  Tumor. — If  in  the  frontal  lobe  no  localizing  symp- 
toms will  be  recognized,  but  there  may  be  certain  alterations  in 
intellect  appreciable  by  the  patient's  family  or  intimates.  Frontal 
lobe  tumors  often  are  found  at  autopsy  on  the  insane.  A  certain 
degree  of  incoordination  may  be  present,  affecting  the  equilibrium 
in  standing  or  walking,  and  causing  resemblance  to  cerebellar  tumors. 
A  tumor  in  the  motor  area  (anterior  to  the  Rolandic  fissure)  will 
produce  first  Jacksonian  epilepsy  (p.  636),  and  later  motor  paralysis 
of  the  opposite  side,  first  of  the  centers  nearest  the  growth,  and  later 
of  the  entire  motor  cortex  of  the  hemisphere  involved.  In  the  'parietal 
lobe  (just  posterior  to  the  fissure  of  Rolando)  sensory  disturbances 
(such  as  loss  of  muscle  sense,  posture  sense,  etc.,  or  word  blindness) 
will  precede  Jacksonian  fits  and  loss  of  motion,  which  latter  phenomena 
will  result  when  the  tumor  reaches  such  a  size  as  to  press  upon  the 
cortex  or  subcortical  fibers  in  front  of  the  fissure  of  Rolando.  A 
tumor  in  the  superior  parietal  convolution  may  cause  astereognosis. 
A  tumor  of  the  occipital  lobe,  or  posterior  part  of  the  parietal  lobe, 
should  be  suspected  if  vision  is  affected  early  (homonymous  hemi- 
anopsia, sometimes  preceded  by  visual  hallucinations,  such  as  flashes 
of  light,  seeing  objects  upside  down,  etc.).  Tumors  in  the  temporo- 
sphenoidal  lobe  give  rise  to  deafness,  loss  of  taste  and  smell,  and  the 
convulsions  which  occur  often  are  preceded  by  a  sensory  aura.    Tumors 


030 


SURGERY  OF   THE  HEAD 


at  the  base  of  the  brain  are  particularly'  characterized  by  paralysis  of 
the  different  cranial  nerves,  as  well  as  by  hemiplegia,  hemianesthesia, 
etc.  Tumors  of  the  hypophysis  cerebri  may  produce  symptoms  of 
hyperpituitarism  (gigantism  in  infants,  acromegaly  in  adults)  or  of 
hypopituitarism  (adiposity,  with  infantilism  in  children,  and  loss 
of  sexual  characteristics  in  adults),  according  as  the  anterior  or 
posterior  portions  of  the  hypophysis  are  involved;  in  either  case, 
the  general  symptoms  of  brain  tumor  are  present,  together  with 
bitemporal  hemianopsia  from  pressure  on  the  optic  chiasm.  A 
skiagraph  may  demonstrate  increase  in  size  of  the  sella  turcica. 
Slibtentorial  tumors  may  be  within  the  cerebellum  or  may  grow  from 

the  meninges.  The  general  symptoms 
occur  early,  and  are  constant  and  severe; 
and  in  addition  to  the  cardinal  symptoms 
of  brain  tumor  already  mentioned,  these 
subtentorial  growths  are  characterized 
especially  by  vertigo,  cerebellar  ataxia, 
nystagmus,  etc.  Most  symptoms  occur 
on  the  same  side  as  the  lesion.  Of  the 
extracerebellar  tumors  those  growing  in  the 
cerebellopontine  angle  are  most  frequent; 
usually  they  are  fibromas,  growing  from 
the  sheath  of  the  eighth  cranial  nerve, 
and  cause  persistent  tinnitus  aurium,  and 
deafness  of  the  same  side;  while  at  a  later 
stage  they  cause  paralysis  of  the  fifth,  sixth, 
and  seventh  nerves,  and  may  finally  sim- 
ulate tumors  within  the  cerebellum  (Fig. 
698).  They  are  lightly  attached  by  a 
small  pedicle,  and  usually  can  be  enu- 
cleated easily.  Intracerebellar  tumors  are 
characterized  by  the  early  development  of 
vertigo,  changes  in  the  eye-grounds  (some- 
times blindness  before  papilledema),  and 
sensations  of  motion  of  self  or  of  surround- 
ing objects;  the  head  is  tilted,  usually 
toward  the  side  of  the  lesion,  and  there  is  staggering  gait,  with  ten- 
dency to  fall  constantly  in  one  direction,  often  toward  the  side  of 
the  lesion.  The  ataxia  is  not  increased  by  shutting  the  eyes.  It  is 
more  marked  in  tumors  of  the  vermis  than  in  those  of  the  hemi- 
spheres. Tumors  of  the  pons  and  medulla  are  rapidly  fatal,  are  not 
amenable  to  operative  treatment,  and  often  cannot  be  distinguished 
from  cerebellar  growths. 

Treatment. — An  untreated  brain  tumor  uniformly  leads  to  death. 
Purely  medical  treatment  is  ineffective  even  in  controlling  the  most  dis- 
tressing symptoms,  pain  and  blindness.  Operation,  merely  by  relieving 
an  internal  hydrocephalus  by  means  of  callosal  puncture  (p.  600)  or  by 
removing  the  overlying  cranium  and  thus  relieving  the  brain  of  pressure 


Fig.  698.  —  Tumor  in  right 
cerebellopontine  angle.  Age 
forty-nine  years.  Symptoms 
began  two  or  three  years  ago; 
worse  for  last  six  to  eight 
months,  since  which  time  there 
have  developed  ataxia,  deaf- 
ness, facial  paralysis,  and  loss 
of  eyesight.  (Paralysis  of  sixth, 
seventh,  eighth  nerves,  paresis 
of  ninth,  and  double  choked 
disk.)  (Dr.  F.  W.  Sinkler's 
patient.)    Orthopaedic  Hospital. 


BRAIN  TUMOR  631 

(decompression)  may  cause  disappearance  of  all  symptoms  for  an  indefi- 
nite period,  even  restoring  sight;  and  in  some  cases  the  tumor  can  be 
removed,  effectually  curing  the  patient.  A  radical  operation,  including 
removal  of  the  tumor,  of  course,  always  is  to  be  preferred;  but  when  an 
unlocalized  tumor  exists,  making  its  presence  known  only  by  the  "  syn- 
drome of  brain  tumor,"  the  surgeon  should  not  hesitate  to  relieve  the 
headache,  check  the  vomiting,  and  prevent  the  development  of  blindness 
or  possibly  to  restore  sight  which  has  failed,  by  means  of  a  palliative 
operation.  After  such  an  operation  it  sometimes  happens  that 
localizing  symptoms  will  develop,  and  thus  enable  the  surgeon  to 
remove  the  tumor  later. 

A  tumor  in  one  of  the  cerebral  hemispheres  is  exposed  by  the 
formation  of  a  bone-flap  (p.  632),  the  bone  being  replaced  after  the 
removal  of  the  tumor.  If  no  tumor  is  found,  or  if  it  cannot 
be  removed  safely,  the  bone  is  removed  from  the  flap,  thus  con- 
verting the  operation  into  one  of  decompression.  Indeed,  Horsley 
never  replaced  the  bone  flap  even  after  the  tumor  had  been  success- 
fully removed.  But  where  decompression  is  planned  in  advance, 
the  subtemporal  operation  of  Cushing  is  to  be  preferred  (p.  634). 
A  tumor  beneath  the  tentorium  is  exposed  by  removal  of  bone  from 
one  or  both  occipital  fossae;  and  the  bone  is  not  replaced.  A  tumor 
of  the  hypophysis  grows  either  toward  the  brain,  or  toward  the  vault 
of  the  pharynx;  this  usually  may  be  determined  by  skiagraphy. 
If  the  tumor  appears  accessible  from  within  the  cranium,  it  is 
best  approached  across  the  anterior  fossa  of  the  skull,  by  means  of  a 
frontal  bone-flap,  according  to  Frazier's  modification  of  McArthur's 
method  (1912) :  a  large  bone-flap  with  external  base  is  elevated  from 
the  right  frontal  region,  and  the  supraorbital  margin  and  roof  of 
the  orbit  are  temporarily  resected.  The  dura  is  opened  and  the  frontal 
lobe  is  elevated  from  the  base  of  the  anterior  fossa,  and  is  incised 
directly  over  the  pituitary  body  (1919).  The  sella  turcica  may  also  be 
approached  by  the  naso-frontal  route  of  Giordano,  employed  by 
Schloffer  (1907),  and  von  Eiselsberg  (1910);  or  by  the  infranasal 
method  of  Kanavel  (1909),  employed  by  Halstead  (1910)  and  by 
Mixter  (1910).  In  Halstead's  operations  a  preliminary  tracheotomy 
was  done,  and  the  pharynx  was  tamponed.  Raising  the  upper  lip, 
an  incision  is  made  through  the  mucous  membrane  of  the  superior 
alveolus,  and  the  cartilaginous  septum  of  the  nose  is  divided.  The 
nose  is  then  retracted  upward.  After  the  bony  septum  and  turbinates 
have  been  excised,  the  anterior  wall  of  the  sphenoidal  sinus  is 
exposed  at  the  bottom  of  the  wound.  This  wall  being  broken 
through,  the  posterior  wall  is  identified.  This  lies  at  a  distance  of 
from  70  to  83  mm.  from  the  anterior  nasal  spine,  and  often  is  thinned 
by  the  growth  of  the  tumor  within  the  sella  turcica.  As  soon  as  the 
latter  cavity  is  opened,  the  tumor  tissue,  which  usually  is  fluid,  is 
evacuated  and  the  cavity  is  lightly  curetted.  The  tumor  cavity  and 
the  entire  wound  are  then  packed  with  iodoform  gauze,  which  emerges 
through  the  nostrils;  the  nose  is  replaced  and  retained  by  a  suture 
or  two,  and  finally  the  alveolar  mucous  membrane  is  sutured. 


632  SURGERY  OF  THE  HEAD 

Temporary  Resection  of  the  Skull  for  Brain  Tumor. — A  skin  flap  is 
outlined  with  ;i  narrow  base  in  the  temporal  region,  the  flap,  which  may 
be  of  any  size,  being  so  situated  as  to  overlie  the  supposed  site  of  the 
tumor.  I  lemorrhage  from  the  scalp  is  most  readily  controlled  by  clamp- 
ing its  whole  thickness  in  numerous  Kocher  hemostats,  at  every  bleed- 
ing-point. The  "head-high"  position  lessens  venous  congestion.  The 
tissues  of  the  scalp  are  not  separated  from  the  underlying  bone,  which  is 
cut  through  in  the  same  lines  as  the  skin  incision.  Various  methods 
are  employed  for  dividing  the  bone:  Frazier  cuts  the  margins  of  the 
bone-flap  by  Cryer's  spiral  osteotome  (1897),  which  is  a  side-cutting 
rotatory  f raise,  propelled  by  a  dental  engine  (Fig.  (599) ;  by  this  method 
a  curved  incision  may  be  made  in  the  skull,  a  trephine  opening  being 
made  each  side  of  the  base  of  the  flap  to  admit  and  to  withdraw  the 
osteotome.  Most  surgeons  make  a  quadrilateral  flap,  boring  holes 
f)  cm.  apart,  and  then  connecting  the  holes  by  cutting  instruments: 
the  Gigli  wire  saw  (1897)  is  employed  for  the  top  of  the  flap,  where  the 
bone  is  thick,  and  this  portion  is  bevelled,  so  that  the  bone  flap  when 
replaced  will  not  sink  against  the  dura;  while  the  thin  sides  of  the  flap, 
in  the  temporal  region  may  be  easily  cut  by  a  De  Vilbiss  cranial 
rongeur  (Fig.  701).  The  easiest  way  to  drill  the  holes  is  by  means  of 
Hudson's  trephine  (Fig.  702).  In  any  case,  after  the  top  and  two 
sides  of  the  bone-flap  have  been  cut  through,  its  narrow  base  (com- 
posed of  the  thin  bone  of  the  temporal  fossa)  is  fractured  by  prying  up 
the  bone-flap  by  two  bone  elevators  (Figs.  684,  3).  Bleeding  from 
the  diploe  is  controlled  by  application  of  minute  slips  of  muscle  tissue 
(cut  from  the  temporal  muscle)  or  by  plugging  with  Horsley's 
wax:  beeswrax,  7  parts;  almond  oil,  1  part;  salicylic  acid,  1  part.  Some 
surgeons  prefer  to  do  this  operation  in  two  stages,  replacing  the  bone- 
flap  and  postponing  exploration  for  the  tumor  until  some  days  later; 
but  unless  unexpected  difficulty  or  delay  has  attended  the  formation 
of  the  bone-flap,  it  is  better  to  conclude  the  operation  in  one  sitting.1 

The  dura,  being  thus  exposed  over  a  wide  area,  is  incised  concentric- 
ally with  the  bone,  leaving  a  sufficient  margin  to  facilitate  closing 
it  again  by  suture.  When  the  cerebral  cortex  is  exposed,  the  tumor 
may  be  found  on  its  surface;  it  then  usually  is  lightly  attached,  and 
may  be  enucleated.  If  no  tumor  is  visible,  it  is  justifiable  to  explore 
the  subcortical  region.  It  is  extremely  important  to  control  hemor- 
rhage from  the  pial  vessels;  any  bleeding  points  should  be  caught 
in  mosquito  hemostats  (Fig.  701)  and  ligated  or  sutured  with  very 
fine  silk.  Sometimes  it  is  sufficient  to  apply  minute  slips  of  muscle 
tissue.  To  explore  the  subcortical  region  an  incision  with  scalpel  is 
made  in  the  middle  of  a  convolution  free  of  vessels,  and  if  an  encap- 
sulated tumor  is  found  it  is  shelled  out  by  blunt  dissection;  a  cyst 
should  be  evacuated  and  its  lining  wall  removed  if  this  is  possible 

1  Cushing  found  that  the  second  stage  of  such  an  operation  may  be  con- 
ducted without  the  use  of  any  anesthetic,  except  "primary  anesthesia"  for  suturing 
the  skin-flap  at  the  end  of  the  operation,  since  the  dura  and  cortex  are  totally 
insensitive  to  gentle  manipulation. 


TEMPORARY  RESECTION  OF  SKULL 


633 


Fig.  699.— Cutting  the  bone-flap  by 
means  of  Oyer's  spiral  osteotome. 


Fig.  701. — Cutting  the  bone-flap  by  means  of 
the  Gigli  wire  saw.      (See  Fig.  544.) 


Fig.  701. — Instruments  used  in  making  a  flap  of  the  skull:  1,  De  Vilbiss's  forceps; 
2,  mosquito  hemostat;  3,  ordinary  hemostat;  4,  Hudson's  trephine  (see  p.  608,  footnote), 
with  four  bits;  5,  the  perforator;  6,  7,  8,  burrs  to  enlarge  the  original  perforation.  (See 
Fig.  702.) 


lip.l 


SURGERY  OF  THE  HEAD 


without  trauma.  A  diffusely  infiltrating  growth  should  not  be 
removed.  I  have  seen  a  surgeon  scoop  out  spoonful  after  spoonful 
of  tissue  from  one  cerebral  hemisphere  which  was  pronounced  by 
several  distinguished  neurologists  who  were  present  to  be  typically 
gliomatous  in  appearance;  yet  microscopical  study  proved  the  tissue 
removed  to  be  normal  cerebral  substance,  while  at  autopsy  the  tumor 
was  found  in  a  totally  different  part  of  the  brain.  Hemorrhage  from 
the  brain  substance  is  controlled  by  extremely  gentle  irrigation 
with  hot  (115°  to  120°  F.)  saline  solution,  or  by  light  pressure  with 
pledgets  of  dry  absorbent  cotton,  or  the  application  of  muscle  tissue. 
The  dural  flap  is  then  sutured  as  accurately  as  possible;  the  bone-flap 
is  replaced,  and  the  skin  is  sutured  tightly  with  closely  set  (0.5  cm. 


Fig.  702. — Hudson's  trephine  in  use. 

apart)  interrupted  sutures  of  silkworm  gut,  which  control  all  bleed- 
ing from  the  scalp.  Never  hurry,  and  use  only  extremely  gentle 
manipulations  in  brain  surgery.  Keep  the  wound  free  from  blood, 
and  avoid  drainage  whenever  possible. 

Decompressive  Operation  for  Brain  Tumor. — As  stated  already, 
temporary  resection  of  the  skull  may  be  converted  into  a  decompressive 
operation  by  removal  of  bone  from  the  flap,  replacing  only  the 
tissues  of  the  scalp.  A  better  operation,  when  decompression  is 
planned  in  advance,  is  the  subtemporal  decompressive  operation  of 
Cushing:  in  this  a  flap  of  skin  is  turned  down  over  the  temporal 
fossa,  exposing  the  temporal  muscle  covered  by  its  aponeurosis; 
these  structures  are  then  divided  down  to  the  bone  in  a  straight 


DECOMPRESSIVE  OPERATION  FOR  BRAIN   TUMOR 


635 


line  parallel  to  the  muscular  fibres,  from  temporal  ridge  to  zygoma; 
by  retracting  the  muscle  a  fairly  large  area  of  cranium  is  exposed; 
this  is  trephined,- and  the  opening  is  enlarged  by  rongeur  forceps 
and  the  dura  is  incised  around  the  margin  of  the  skull  opening  and 
is  left  unsutured.  The  muscle  and  the  skin-flap  are  then  sutured, 
without  drainage.  The  hernia  cerebri,  which  results,  protrudes 
beneath  the  temporal  muscle,  which  acts  as  support,  rendering  the 
deformity  less  conspicuous,  but  if  the  intracranial  pressure  continues  to 
increase,  the  hernia  may  become  immense  (Fig.  704),  and  may  even 
cause  sloughing  of  the  overlying  scalp.  A  similar  decompressive 
operation  on  the  occipital  bone  may  be  employed  in  cases  of  inoper- 
able cerebellar  tumors.     It  may  be  impossible  to  close  the  scalp,  in 


Fig.  703. — Cicatrix  of  operation  by 
bone  flap  for  middle  meningeal  hemor- 
rhage. See  Fig.  691.  Episcopal  Hos- 
pital. 


Fig.  704. — Hernia  cerebri  fol- 
lowing bilateral  subtemporal  de- 
compression for  unlocalized 
tumor.     Orthopaedic  Hospital. 


some  cases  of  inoperable  brain  tumor,  after  decompression  has  been 
accomplished,  owing  to  the  protrusion  of  the  hernia  cerebri;  but  if 
necessary  this  may  be  diminished  by  elevating  the  patient's  head,  or 
by  lumbar  or  ventricular  puncture. 

Patients  may  live  for  months  or  years  after  a  decompressive  opera- 
tion, being  symptomatically  relieved  until  rapid  death  results  from 
some  incurable  complication. 

Fungus  Cerebri  should  be  distinguished  from  hernia  cerebri, 
mentioned  above.  The  former  is  an  old  term  which  it  is  convenient 
to  retain  to  describe  granulations  ("proud  flesh")  springing  from 
cerebral  substance  exposed  in  a  wound,  and  developing  as  the  result 
of  infection.  Fungus  cerebri  may  occur  in  cases  of  compound  frac- 
ture, with  rupture  of  the  dura  and  protrusion  of  brain  substance; 
or  in  cases  of  hernia  cerebri  secondarily  infected  from  sloughing  of 
the  overlying  scalp.  The  treatment  consists  in  antiseptic  and  astrin- 
gent applications,  of  which  alcohol  is  the  most  effective.    This  grad- 


630  SURGERY  OF  THE  HEAD 

ually  causes  the  granulations  to  shrivel  up.  If  the  fungus  is  cut  off 
with  scissors  it  will  soon  return  unless  the  infection  is  controlled  and 
the  wound  begins  to  cicatrize  and  contract. 

Focal  or  Jacksonian  Epilepsy,  named  after  Hughlings  Jackson, 
who  particularly  studied  the  condition  in  1873,  was  referred  to  at 
p.  628,  as  an  occasional  symptom  of  brain  tumor.  It  is  characterized 
by  convulsive  attacks  beginning  in  one  muscle  or  group  of  muscles, 
gradually  spreading  until  finally  a  generalized  convulsion  ensues. 
Consciousness  may  persist  until  the  convulsions  become  general, 
or  it  may  not  be  lost  at  all.  It  is  thus  distinguished  from  ordinary 
("idiopathic")  epilepsy,  in  which  the  fits  are  general  from  the  first 
and  in  which  unconsciousness  ushers  in  the  attack.1  Jacksonian 
epilepsy  is  believed  to  be  due  either  to  some  localized  cortical  lesion, 
or,  rarely  (and  then  most  often  in  children  and  women),  to  some 
peripheral  sensory  irritation,  arising  from  a  painful  cicatrix  or  other 
lesion  such  as  eye-strain,  dental  disorders,  genital  affections,  etc. 

In  cases  due  to  cortical  lesion  the  most  frequent  cause,  apart  from 
tumor,  is  the  result  of  old  trauma;  this  may  have  been  a  depressed 
fracture,  or  a  meningeal  hemorrhage  producing  a  meningo-cortical 
adhesion,  a  cyst,  or  a  cicatrix.  Similar  lesions  may  be  the  result 
of  intracranial  infections,  especially  in  children,  in  whom  focal  epilepsy 
may  develop  after  an  attack  of  meningitis,  encephalitis,  etc. 

Treatment. — As  there  is  no  medical  cure  for  these  cases,  it  is  per- 
fectly justifiable  to  consider  what  benefits  may  be  gained  from  surgical 
intervention  if  a  definite  lesion  can  be  located.  Nor  should  the 
surgeon  hesitate  to  operate  for  any  surgical  condition  in  another 
part  of  the  body  in  an  epileptic  patient  merely  because  occasional 
fits  occur;  for  it  happens  occasionally  that  cure  of  a  lesion  not  sus- 
pected of  having  any  causal  relation  with  the  epilepsy  results  in 
freedom  from,  or  at  least  in  a  lessening  in  frequency  of  the  convulsions. 

If  a  meningeal  or  cortical  lesion  is  suspected,  the  center  controlling 
the  muscle  group  first  affected  is  exposed  by  a  skull  flap.  Depressed 
bone  is  removed;  adherent  dura  is  excised,  and  the  reformation  of  adhe- 
sion is  prevented  by  the  interposition  of  free  transplants  of  fascia  lata 
or  fat.  Little  can  be  done  for  lesions  in  the  cerebral  substance.  The 
proper  center  may  be  identified  by  faradization  of  the  cortex.  Kocher 
(1899)  believed  a  decompression  operation  alone  was  of  benefit.  The 
sooner  any  operation  is  done  after  the  development  of  focal  epilepsy, 
the  more  apt  is  it  to  be  curative;  and  if  all  head  injuries  received 
efficient  treatment  at  the  time  of  the  original  accident,  the  number 
of  cases  of  Jacksonian  epilepsy  would  be  much  decreased. 

1  Advances  in  knowledge  constantly  are  diminishing  the  number  of  cases  of  true 
"idiopathic"  epilepsy,  and  it  is  not  impossible  that  only  our  ignorance  prevents 
a  recognition  of  an  organic  lesion  in  all  such  cases. 


CHAPTER  XVIII. 

SURGERY  OF  THE  SPINE. 

Spina  Bifida,  or  Hydrorrachis. — Under  these  names  are  included 
several  forms  of  congenital  malformation  of  the  spine,  due  to  failure 
of  proper  coalescence  in  the  embryonal  medullary  plates.  Myelocele, 
or  Rachischisis,  is  the  most  complete  form.  In  this  the  skin  is  defi- 
cient, and  there  is  exposed  on  the  back  of  the  infant,  usually  in  the 
lumbar  region,  a  dark  red  area  covered  by  endothelium,  which  is  con- 
tinuous above  and  below  with  the  central  canal  of  the  spinal  cord. 
The  infant  often  presents  other  serious  malformations,  and  usually 
is  stillborn  or  dies  within  a  few  days  from  continual  leakage  of 
cerebrospinal  fluid,  or  from  infection.  Syringomyelocele:  Here  the 
central  canal  of  the  spinal  cord  is  distended  with  fluid,  the  surround- 
ing cord  is  compressed  and  atrophic,  and  protrudes  as  a  cystic  tumor 
through  a  defect  in  the  vertebral  laminae.  The  protrusion,  which  is 
covered  by  skin,  or  membrane,  usually  occurs  to  one  side,  and  not 
in  the  midline.  Meningomyelocele  is  by  far  the  commonest  of  these 
deformities,  occurring  in  nearly  two-thirds  of  all  cases  of  spina  bifida. 
The  cystic  protrusion  is  formed  by  fluid  which  collects  in  the  meshes 
of  the  arachnoid,  and  the  roots  of  the  spinal  nerves  are  spread  out 
over  the  walls  of  the  sac.  If  the  sac  presents  a  dimple  or  furrow  on  its 
surface  it  is  probable  that  the  cord  itself  is  adherent.  The  laminae  of 
one  or  several  vertebrae  may  be  deficient.  Meningocele,  in  which  the 
protrusion  involves  only  the  spinal  membranes,  and  never  the  nerve 
roots  or  the  cord  itself,  occurs  only  in  about  8  per  cent,  of  cases. 
The  tumor  is  small,  covered  throughout  with  healthy  skin,  never 
presents  a  dimple  or  a  furrow,  and  usually  is  more  or  less  pedunculated, 
its  orifice  of  communication  with  the  spinal  canal  being  small.  In 
meningomyelocele,  on  the  contrary,  the  protrusion  is  large,  sessile, 
and  communicates  with  the  spinal  canal  through  a  large  defect;  and 
while  healthy  skin  may  extend  upward  from  its  base  some  distance,  the 
summit  of  the  protrusion  usually  is  covered  by  membrane  which  easily 
becomes  inflamed  and  sloughing  is  frequent.  Paralysis  of  the  parts 
below  the  tumor  points  to  a  condition  of  meningomyelocele  rather 
than  of  pure  meningocele,  and  it  may  develop  only  as  growth  of  the 
child's  body  draws  the  spinal  cord  away  from  the  skin  covering  the 
protrusion,  to  which  it  is  usually  adherent.  If  there  is  a  defect  in 
the  bony  wall  of  the  vertebral  canal,  without  the  protrusion  of  any 
of  its  contents,  the  condition  is  known  as  Spina  Bifida  Occulta;  this 
usually  is  accompanied  by  hypertrichosis  of  the  region  affected.1     In 

1  The  only  difference  in  pathogenesis  between  this  and  ordinary  spina  bifida  is 
that  in  the  latter  there  is  abnormality  in  secretion  or  absorption  of  the  cerebro- 
spinal fluid,  in  addition  to  the  congenital  deformity. 

(637) 


C38 


SURGERY  OF  THE  SPINE 


very  rare  cases  there  has  been  a  defect  in  the  anterior  portions  of  the 
vertebral  canal,  constituting  Spina  Bifida  Anterior. 

Symptoms. — Besides  the  presence  of  a  cystic  growth,  usually  in  the 
lumbar  or  sacral  regions  of  the  spine,  it  may  be  possible  to  ascertain 
by  palpation  or  skiagraphic  examination  that  a  defect  exists  in  the 
vertebra?.  Compression  of  the  spina  bifida  usually  causes  increased 
tension  in  the  cranial  fontanelles,  and  may  produce  convulsions. 
Tension  of  the  cyst  is  increased  during  expiration,  and  when  the  child 
is  in  the  upright  position. 

Treatment. — 1.  //  there  are  other  serious  malformations,  or  extensive 
I  hi  rah/si*,  no  radical  treatment  should  be  adopted,  as  most  of  these 

patients  will  die  within  the  first 
year  under  any  circumstances. 
Efforts  to  avoid  infection  should 
be  made,  by  preventing  excori- 
ation of  the  sac.  If  such  patients 
survive  more  than  five  years, 
operative  treatment,  as  detailed 
below,  will  be  proper.  2.  If  there 
are  no  other  serious  malformations 
and  no  paralyses,  the  treatment  to 
be  adopted  depends  upon  the  con- 
dition of  the  coverings  of  the  spina 
bifida:  when  these  are  healthy,  as 
in  most  cases  of  pure  meningocele, 
operation  should  be  postponed  until 
the  child  is  five  years  of  age;  when 
the  coverings  are  thin  or  membran- 
ous, the  risk  from  delay  is  as  great 
as,  if  not  greater  than  that  from 
early  aseptic  operation.  Imme- 
diate operation  may  be  required  at  any  time  for  rupture  of  the  sac, 
but  when  a  choice  is  possible,  operation  during  the  second  or  third 
month  of  life  is  to  be  preferred  (Lovett,  1907). 

Operation  usually  consists  in  excision  of  the  sac,  preserving  healthy 
skin  coverings,  and  carefully  dissecting  free  adherent  nerves,  but 
cutting  away  those  that  cannot  be  preserved,  as  they  probably  are 
functionless  (Carson).  The  sac  walls  are  then  overlapped,  as  in  radical 
cure  of  umbilical  hernia,  and  the  muscles  and  skin  are  sutured  in 
separate  layers,  and  the  wound  is  closed  tightly  without  drainage. 
The  death  rate  following  operation  is  from  25  to  35  per  cent.,  and 
hydrocephalus  sometimes  develops  as  a  result.  Heile  (1910)  employed 
drainage  of  the  sac  into  the  peritoneal  cavity  by  means  of  subcutaneous 
silk  threads,  with  coincident  cure  of  a  complicating  hydrocephalus. 
In  some  cases,  even  of  spina  bifida  occulta,  disability  may  persist 
in  later  life  from  weakness  of  the  spinal  column.  For  such  cases  bone 
transplantation,  as  in  tuberculosis  of  the  spine,  may  secure  relief. 
Sacro-coccygeal  Tumors. — See  Chapter  IV. 


Fig.  705. — Spina  bifida.     Age   eighteen 
months.     Orthopaedic  Hospital. 


INJURIES  OF  THE  SPINE  639 

INJURIES  OF  THE  SPINE. 

Strains. — Strains  of  the  back,  affecting  the  muscular  and  aponeu- 
rotic structures,  are  much  more  frequent  than  true  sprains  affecting  the 
spinal  joints.  According  to  the  severity  of  the  injury,  these  patients 
are  to  be  treated  by  rest  in  bed,  or  as  ambulatory  cases,  support  being 
provided  during  the  painful  stages  by  adhesive  plaster  strapping  or 
plaster  of  Paris  jackets.  Restoration  of  function  may  be  aided  later 
by  massage. 

Sprain-fracture. — Sprain-fracture  of  the  transverse  processes  of  the 
lumbar  vertebrse,  unilateral,  occasionally  occurs  from  muscular  action. 
Tanton  (1910)  collected  17  cases  of  this  injury.  Skillern  (1913) 
reported  a  case  of  sprain-fracture  of  a  spinous  process. 

Static  Lesions  of  the  Lumbar  Spine  and  Spondylolisthesis  are 
discussed  in  Chapter  XVI. 

Concussion  of  the  Spinal  Cord. — This  term  has  been  used  to 
define  a  condition  supposed  to  be  more  or  less  analogous  to  con- 
cussion of  the  brain  (p.  614).  It  implies  that  there  has  been  injury 
to  the  spinal  cord  without  lesion  of  the  vertebral  column;  and  while 
some  hold  that  the  symptoms  which  follow  a  supposed  injury  have  no 
pathological  basis  for  their  existence,  being  merely  one  form  of  neurosis, 
other  authorities  believe  that  actual  changes  in  the  cord  have  taken 
place,  and  have  left  more  or  less  irreparable  damage.  Many  of  these 
patients  receive  their  injury  in  railroad  accidents,  and  the  condition 
which  ensues  is  popularly  known  as  "  Railway  Spine,"  or,  because  of 
the  improvement  which  usually  follows  the  settlement  of  a  suit  for 
damages,  as  "Litigation  Spine."  As  a  matter  of  fact  it  is  probable  that 
most  of  these  cases  should  be  considered  severe  strains  or  sprains  of 
the  back,  and  the  surgical  treatment  is  the  same.  For  the  hysterical 
symptoms  which  sometimes  ensue,  the  patients  should  be  referred 
to  a  neurologist. 

Hematorrachis. — Hematorrachis  or  hemorrhage  into  the  spinal 
canal,  usually  is  extradural  and  seldom  exists  as  an  isolated  lesion, 
but  complicates  fracture-dislocations  of  the  vertebral  column.  It 
manifests  its  presence  first  by  irritation  then  by  pressure  symptoms 
(p.  665),  and,  if  intradural,  is  readily  recognized  by  lumbar  puncture. 
If  this  does  not  relieve  the  symptoms  of  compression,  laminectomy 
is  indicated. 

Hematomyelia. — Hematomyelia,  or  hemorrhage  into  the  substance 
of  the  spinal  cord,  sometimes  occurs  from  sudden  twists  or  angula- 
tions of  the  vertebral  column,  perhaps  from  a  self-reduced  subluxation, 
without  discoverable  gross  lesion  of  the  spinal  column.  It  is  seen 
oftenest  in  the  lower  cervical  region  (Thorburn,  1889),  and  causes 
paralysis  depending  upon  the  extent  of  the  lesion  (Fig.  706).  Usually 
the  lower  extremities  recover  from  the  paralysis  more  or  less  rapidly, 
though  they  may  remain  spastic,  while  the  flaccid  paralysis  of  the 
upper  extremities  continues  longer  and  may  be  permanent.  There  is 
dissociated  anesthesia  below  the  level  of  the  lesion;  that  is,  while 


640 


SURGERY  OF  THE  SPINE 


tactile  sensation  is  preserved,  temperature  and  pain  sense  are  dimin- 
ished or  lost.  Lumbar  puncture  shows  no  blood  in  the  cerebrospinal  fluid. 

Stab  Wounds. — Stab  wounds  in- 
volving the  spinal  cord  are  very  rare. 
From  unilateral  lesion  a  monoplegia 
may  result.  It  is  best  in  civil  life  to 
explore  such  wounds  by  laminectomy 
(p.  647),  as  it  may  be  possible  to  re- 
pair the  injury. 

Fractures  and  Dislocations  of  the 
Spinal  Column. — Fracture  and  dislo- 
cation occur  as  a  combined  lesion  in 
about  60  per  cent,  of  cases  of  injury 
of  the  spinal  column,  while  isolated 
fractures  and  dislocations  form  each 
about  20  per  cent,  of  these  injuries. 
The  spine  is  most  subject  to  injury 
where  its  mobile  and  immobile  por- 
tions meet,  that  is,  in  the  lower  cer- 
vical and  the  dorso-lumbar  regions. 
Pure  dislocations  are  very  rare  except 
in  the  cervical  region,  as  the  form  of 
the  articular  processes  renders  fracture  almost  a  necessary  complica- 
tion in  other  portions  of  the  vertebral  column.    Fractures  of  the  laminae 


Fig.  706. — Hematoniyelia,  showing 
residual  paralyses.  Patient  fell  from 
a  height,  acutely  flexing  his  neck.  For 
a  week  there  was  complete  paralysis 
below  the  neck,  then  gradual  recovery. 
Episcopal  Hospital. 


Fig.  707. — Fracture  dislocation  of  eleventh  and  twelfth  thoracic  vertebrae.     From   a 
specimen  in  the  Mutter  Museum  of  the  College  of  Physicians  of  Philadelphia. 

or  spinous  processes  usually  occur  from  direct  violence,  as  in  gunshot 
wounds,  or  in  falls  from  a  height  directly  upon  the  back,  impinging 


INJURIES  OF  THE  SPINE 


041 


on  a  stone,  fence  rail,  etc.  The  most  common  lesion  is  a  crushing 
fracture  of  the  bodies  of  one  or  more  vertebrae,  attended  by  forward 
dislocation  of  the  vertebra  next  above,  the  disjunction  of  the  articular 
processes  taking  place  on  one  or  both  sides  (Fig.  707).  Such  cases 
generally  are  caused  by  sudden  hyperflexion,  with  twist,  of  the  spinal 
column,  as  falls  from  a  height  on  to  the  feet  or  the  buttocks,  crushing 
injuries  from  above  acting  upon  the  shoulders,  or  from  a  dive  into 
shallow  water.  Violence  acting  upon  the  head  or  neck  usually  pro- 
duces a  lesion  in  the  lower  cervical  region,  and  that  acting  from  below 
determines  lesions  in  the  dorso-lumbar  portion  of  the  spine. 

Symptoms. — These  may  be  divided  into  those  due  to  injury  of  the 
vertebral  column,  and  those  caused  by  accompanying  lesions  of  the 
spinal  cord.  It  is  said  that  the  cord  escapes  injury  in  about  one-third 
of  the  cases. 

Symptoms  from  Injury  of  the  Vertebral  Column. — Of  these,  deformity 
is  of  most  value.  This  may  consist  in  a  depression  at  the  point  of 
injury,  especially  when  the  fracture  is 
from  direct  violence,  the  spines  and 
laminae  being  driven  forward;  or  it 
may  indicate  that  there  is  a  partial 
forward  dislocation  of  the  vertebra 
whose  spine  is  depressed.  Such  a  de- 
pression is  most  apt  to  be  found  in  a 
dorso-lumbar  injury.  In  some  cases 
there  is  angular  deformity,  a  well  defined 
kyphos  existing  at  the  point  of  injury 
and  indicating  the  collapse  of  a  verte- 
bral body,  causing  separation  of  the 
spinous  processes.  Rotatory  deformity 
is  seen  oftenest  in  the  cervical  region, 
in  cases  of  unilateral  dislocation:  the 
head  is  twisted  away  from  the  side 
which  is  luxated,  and  this  side  may 
be  unduly  prominent;  the  sterno- 
mastoid  muscle  on  the  uninjured  side 
is  more  tense  than  is  that  on  the  in- 
jured side.  Other  symptoms  of  frac- 
ture,  such  as  mobility  and  crepitus, 

seldom  are  present ;  but  persistent  localized  tenderness  is  very  suggestive 
of  vertebral  injury,  and  in  the  cervical  region  muscular  spasm,  producing 
rigidity  of  the  neck,  is  a  very  usual  symptom,  especially  in  lesions  of 
the  vertebrae  without  injury  of  the  cord.  A  good  skiagraph  may  be 
necessary  to  assure  the  diagnosis  in  obscure  cases. 

Symptoms  from  Injury  of  the  Spinal  Cord.  Motor  Symptoms. — Motor 
paralysis  is  the  most  striking  and  one  of  the  most  constant  symptoms, 
and  involves  all  the  muscles  below  the  seat  of  the  lesion.  Usually  it 
follows  the  injury  immediately,  and  then  indicates  extensive  destruc- 
tion of  the  cord,  as  a  rule  from  crush  due  to  displaced  bone  (Fig.  70S). 
41 


Fig.  708.  —  Crushing  fracture  of 
first  lumbar  vertebra.  Mutter 
Museum. 


642 


SURGERY  OF  THE  SPINE 


If  the  onset  of  the  paralysis  is  delayed,  it  probably  is  the  result  of 
hemorrhage  either  within  the  cord  {hematomyelia)  or  in  the  arach- 
noid spaces  (hematorrachis).  In  the  latter,  paralysis  of  motion  usually 
is  more  marked  f than  is  that  of  sensation,  and  gradually  extends 
upward,  perhaps  in  the  course  of  a  few  hours.  In  all  cases  the  primary 
paralysis  is  flaccid,  and  the  patient  is  free  from  pain,  at  least  in  the 
early  stages.  If  the  paralysis  becomes  spastic  very  soon  (twelve  to 
twenty-four  hours)  after  the  injury,  and  if  the  reflexes  are  present, 
it  usually  indicates  only  partial  destruction  of  the  cord,  from  contu- 
sion, pressure  from  displaced  bone,  hematorrachis,  etc.  Paralysis 
which  first  develops  some  days  after  a  spinal  injury  usually  is  due  to 
inflammatory  exudation  or  blood  clot.  But  lumbar  puncture  rarely 
shows  blood  in  the  cerebrospinal  fluid. 


Fig.  709. — Fracture  of  cervical  vertebrae.  Characteristic  position  of  arms  when  the 
lesion  is  above  the  sixth  cervical  segment.  The  external  rotators  of  the  shoulder  and 
flexors  of  the  elbow  escape.     (See  Fig.  711,  and  Plate  IV,  p.  316.)     Episcopal  Hospital. 


In  the  cervical  region,  symptoms  of  cord  injury  may  be  obscured 
at  first  by  those  due  to  cerebral  concussion,  caused  by  the  same  injury. 
If  the  lesion  is  above  the  fourth  cervical  segment,  causing  paralysis 
of  the  diaphragm,  immediate  or  rapid  death  is  usual.  Symptoms 
from  paralysis  of  the  cervical  sympathetic  may  be  present.  Char- 
acteristic attitudes  may  be  assumed  owing  to  unopposed  action  of 
intact  muscles  (Fig.  709),  as  noted  in  1894  by  Thorburn. 

If  the  lesion  is  below  the  second  lumbar  vertebra,  paralysis  may  be 
absent  or  only  partial,  owing  to  the  fact  that  the  spinal  cord  itself 
does  not  extend  beyond  this  level,  and  the  injury  may  involve  only 
some  of  the  branches  of  the  cauda  equina  (Fig.  710) .  In  rare  cases  only 
unilateral  (homolateral)  paralysis  may  exist;  this  is  much  more  usual 
in  stab  and  gunshot  wounds  than  in  cases  of  fracture-dislocation. 


INJURIES  OF  THE  SPINE 


643 


At  a  later  date  (after  a  week  or  ten  days)  it  is  very  usual  for  the 
patient  to  experience  painful  spasms  in  the  paralyzed  limbs;  and  as 
cicatricial  changes  in  the  cord  progress  the  type  of  paralysis  becomes 
spastic,  and  contractures  develop  (Fig.  285). 


Fig.  710. — ^Fracture-dislocation  of  the  third  and  fourth  lumbar  vertebrae.  Five 
months  after  injury  the  only  residual  effects  were  weakness  of  left  peroneal  muscles  and 
some  anesthetic  areas  on  right  thigh.     Episcopal  Hospital. 


Sensory  Symptoms. — Sensation  is  lost  over  an  area  corresponding 
to  that  of  paralysis  of  motion,  and  the  upper  limit  of  the  motor  and 
sensory  paralysis  is  sharply  defined,  thus  determining  the  level  of  the 
injury  (Fig.  711).  Pain  rarely  is  severe,  though  a  zone  of  hyperesthesia 
is  not  infrequent  at  the  upper  border  of  the  anesthetic  area.  Shooting 
pains,  from  irritation  of  the  sensory  nerve  roots,  are  more  common 
in  partial  cord  lesions,  and  often  occur  when  recovery  from  severer 
lesions  is  beginning.  Dissociated  anesthesia,  as  already  mentioned, 
is  frequent  in  hematomyelia. 


lilt 


SURGERY  OF   THE  SPINE 


_A7.  to  rectus  lateralis 
_il(o  rectus  antic  minor 
-Anastomosis  with  hypoglossal 

Anastomosis  with  pncnmogastrio 
.V.  to  rectus  antic. major. 

_.N.  to  mastoid  region. 

.^Oreat  auricular  n. 

•  -Transverse  cervical  n. 

F=£ \N.  to  Trapezius,  Ana.  Scap.  and  Rhomboid. 


Supra'davieular  n. 

Supra-acromial  n. 
Phrenic  n. 

N.  to  levator  ang.  scap. 

JV.  to  rhomboid 

Subscapular  n. 

Subclavicular  n. 


iV.  to peetoralis  major. 


.Circumflex  n. 

Musculocutaneous  n. 

Median  n. 

Radial  n. 

Ulnar  n. 

Internal  cutaneous  n. 

Small  internal  cutaneous  n. 


IUo-hypogastrtc  n. 
llio-inguinal  n. 


..External  cutaneous  n, 
.Genito-crural  n. 


Anterior  crural  it. 
Obturator  n. 


N.  to  levator  ant -<Z^ 

N.  to  obturator  int. ._J?5_ 

N.  to  sphincter  ani Z\_ 

Coccygeal  n _\ 

Co.l 


Superior  gluteal  n. 


N.  to  pyriformis 

X.  to  gemellus  super. 


to  gemellus  infer, 
to  quadrutus 

Siytall  sciatic  n. 
Sciatic  n. 


u^iP'-J11' — Tlle  re'at,on  of  the  segments  of  the  spinal  cord  and  their  nerve  roots  to 
the  bodies  and  spines  of  the  vertebrae.  (Dejerine  et  Thomas,  Mai.  d.  1.  Moelle  Epiniere, 
Pans,  1902.) 


PLATE   VI 


Diagram  of  Segmental  Distribution  of 
the  Cutaneous  Nerves  of  the  Right  Upper 
Extremity.     Anterior  View.     (Gray.) 


Diagram  of  Segmental  Distribution  of 
the  Cutaneous  Nerves  of  the  Right  Upper 
Extremity.     Posterior  View.     (Gray.) 


PLATE   VJI 


Diagram  of  Segmental  Distribution 
of  the  Cutaneous  Nerves  of  the  Right 
Lower  Extremity.     Front  View.     (Gray.) 


Diagram  of  Segmental  Distribution  of 
the  Cutaneous  Nerves  of  the  Right  Lower 
Extremity.     Posterior  View.     (Gray.) 


INJURIES  OF  THE  SPINE  645 

Bed-sores,  especially  over  the  sacrum  and  heels,  are  very  prone  to 
develop  in  cases  of  spinal  injury,  being  described  as  due  to  trophoneu- 
rotic disturbances.  Whatever  is  the  true  explanation,  the  probability 
of  their  early  development  (within  two  or  three  days)  always  should 
be  borne  in  mind,  and  preventative  measures  instituted. 

Abdominal  and  Vesical  Symptoms.- — Owing  to  the  motor  paralysis 
affecting  the  muscles  of  the  abdominal  wall,  and  perhaps  the  muscular 
tunics  of  the  intestines,  tympanites  develops.  If,  as  is  usual,  the  lesion 
is  above  the  spinal  centers  for  the  bladder  and  rectum  (in  the  second, 
third,  and  fourth  sacral  segments),  there  is  retention  with  orerfloiv  of 
the  urine  and  feces,  as  the  voluntary  impulses  from  the  cerebrum 
cannot  reach  the  spinal  centers,  and  the  sphincters  remain  tonically 
contracted  until  overflow  occurs.  The  bladder  becomes  distended, 
and  only  the  surplus  urine  dribbles  away;  feces  accumulate  in  the 
rectum,  and  this  is  emptied  only  by  enema,  or  finally  by  exhaustion 
of  the  sphincter.  If,  however,  what  is  very  rare,  the  lesion  is  so 
low  as  to  damage  these  centers  themselves,  or  the  nerves  between 
them  and  the  bladder  or  rectum,  then  true  incontinence  of  urine  and 
feces  occurs,  the  bladder  remaining  empty,  while  the  urine  and 
feces  are  passed  involuntarily,  and  more  or  less  continuously.  Cys- 
titis usually  develops,  as  a  consequence  of  the  habitual  use  of  the 
catheter.  Priapism,  occurring  soon  after  the  injury,  is  common, 
especially  in  younger  patients,  and  is  said  to  be  more  frequent  in  severe 
and  high  lesions  than  in  those  at  a  lower  level,  or  those  in  which  there 
is  only  partial  destruction  of  the  cord. 

Prognosis. — It  long  has  been  a  rule  of  thumb  that  when  the  frac- 
ture is  in  the  cervical  spine  the  patients  will  live  a  week,  those  with 
fracture  of  the  thoracic  spine  a  month,  and  those  with  fracture 
of  the  lumbar  spine  a  year;  and  this  may  still  be  considered  a  fairly 
accurate  prognosis  when  there  is  evidence  of  complete  transverse 
lesion  of  the  cord.  But  in  the  cervical  region  it  is  not  unusual 
for  the  cord  to  escape  injury,  mainly  owing  to  the  large  size  of  the 
spinal  canal.  J.  and  A.  Boeckel  (1911)  collected  36  such  cases.  In 
injuries  of  the  thoracic  and  lumbar  regions,  life  may  be  preserved 
indefinitely  if  such  complications  as  bed-sores,  cystitis,  and  pyoneph- 
rosis can  be  prevented;  and  if  the  cord  is  not  totally  destroyed,  careful 
nursing  may  enable  a  certain  amount  of  power  to  be  regained. 

Treatment. — No  hesitancy  should  be  felt  in  reducing  any  deformity 
present,  especially  in  the  cervical  region;  but  this  should  be  done 
judiciously,  and  with  a  clear  idea  of  the  mechanism  of  the  injury. 
The  fact  that  one  or  more  such  attempts  have  resulted  in  the  patient's 
immediate  death,  demonstrated  nothing,  as  pointed  out  by  Mal- 
gaigne,  as  long  ago  as  1843,  but  that  the  attempts  were  unskilfully 
made  by  an  incompetent  person.  In  studying  nearly  400  cases  of 
spinal  injury,  John  Ashhurst,  Jr.  (1867)  found  that  in  the  treatment 
of  dislocations  in  the  cervical  region  the  mortality  had  been  nearly 
four  times  greater  when  no  attempts  were  made  to  reduce  the 
deformity,  than  when  this  was  undertaken  by  extension,  rotation, 


646  SURGERY  OF  THE  SPINE 

etc.  Walton  (1S92)  systematized  the  reduction  of  these  injuries, 
omitting  attempts  at  extension  (longitudinal  traction),  which  he 
demonstrated  to  be  useless,  and  employing  only  "  retro-lateral  flexion 
and  rotation,"  in  the  unilateral  cervical  dislocations,  which  are  the 
most  frequent  cases.  Reduction  is  accomplished,  after  etherizing 
the  patient,  in  this  manner:  the  surgeon  stands  behind  the  seated 
patient,  and  grasps  the  head  between  his  hands;  the  head  is  then 
tilted  backward,  and  flexed  slightly  away  from  the  dislocated  side, 
so  as  to  release  the  dislocated  articular  process  from  the  interver- 
tebral foramen  of  the  vertebra  next  below,  where  it  is  usually  caught. 
The  head  is  then  rotated  so  as  to  carry  the  dislocated  side  backward. 
Reduction  of  the  deformity  may  be  attended  by  an  audible  or  pal- 
pable click.  The  patient  should  remain  in  bed,  with  the  head  and 
neck  immobilized  by  plaster  of  Paris  dressings,  or  by  sand-bags  with 
weight  extension  (as  in  cervical  Pott's  disease,  p.  650)  for  a  couple 
of  weeks,  and  some  retentive  appliance  should  be  worn  for  some 
weeks  longer,  or  until  the  ruptured  ligaments  have  had  a  chance  to 
heal.  Bilateral  cervical  dislocations  may  be  reduced  by  the  same 
method,  applied  to  each  side  separately.  The  deformity  from  frac- 
ture, seldom  present  except  in  the  thoracic  and  lumbar  regions, 
usually  is  best  corrected  by  hyperextension  of  the  spine. 

In  every  case  with  cord  injury,  the  patient  should  be  kept  on  a 
water  bed,  with  head  and  foot  extension,  as  in  tuberculosis  of  the 
spine  (p.  656) ;  and  the  utmost  care  should  be  taken  to  prevent  the 
development  of  bed-sores  (p.  62).  The  bladder  should  be  drained 
by  an  inlying  catheter,  if  there  is  retention  of  urine;1  and  the  bowels 
generally  have  to  be  moved  by  enemas.  In  most  cases  nothing  further 
can  be  done  than  to  keep  the  patient  comfortable  by  careful  nursing. 
If  life  is  preserved,  efforts  must  be  made  to  maintain  the  nutrition 
of  the  paralyzed  parts  by  massage;  the  development  of  deformities 
from  contractures  (Fig.  285)  should  be  guarded  against,  though  these 
may  be  corrected  later  by  tenotomies;  and  eventually  such  orthopedic 
apparatus  as  is  indicated  should  be  provided,  as  in  this  way  patients 
otherwise  nearly  helpless  may  regain  some  power  of  locomotion. 

The  Question  of  Operation. — In  cases  where,  after  the  first  few  days, 
it  seems  that  the  cord  has  not  been  completely  destroyed — as  evi- 
denced by  persistence  of  reflexes,  early  development  of  spasticity, 
with  shooting  pains,  spasmodic  contractions,  etc. — it  is  justifiable  to 
expose  the  injured  cord  by  laminectomy,  in  the  hope  that  evacuation 
of  blood-clot  (almost  always  extradural)  or  even  the  removal  of 
counter-pressure  on  the  cord  by  the  lamina?  and  arches,  may  accel- 
erate the  cure.  But  it  is  in  just  such  cases  as  these  that  a  fair  amount 
of  improvement  may  occur  without  operation;  yet  as  this  cannot  be 
certain  beforehand,  and  as  operation  in  such  carefully  selected  cases 

1  Some  surgeons  condemn  the  use  of  the  catheter,  and  trust  to  gentle  pressure 
above  the  pubes,  repeated  periodically,  to  empty  the  bladder;  they  believe  that 
the  sphincter  always  becomes  relaxed  before  injurious  distention  of  the  bladder 
occurs. 


INJURIES  OF  THE  SPINE  647 

does  not  increase  the  mortality,  I  think  it  should  be  employed.  Very 
early  operation  (on  the  day  of  injury,  if  possible),  is  proper  in  all  cases 
where  the  spines  and  laminae  have  been  driven  inward  against  the 
cord  by  direct  violence;  since  in  such  cases  it  is  reasonably  sure  that 
the  displaced  fragments  continue  to  compress  the  cord,  or  that  hema- 
torachis  will  develop  later.  The  same  is  true  of  gunshot  wounds  of 
the  vertebral  column,  in  civil  life,  involving  the  arches;  these  should 
be  treated  by  laminectomy  and  removal  of  displaced  fragments, 
whether  or  not  there  are  cord  symptoms. 

In  other  cases,  with  symptoms  of  complete  transverse  lesion,  in 
most  of  which  the  osseous  lesion  is  collapse  of  the  vertebral  bodies,  it 
is  extremely  probable  that  the  cord  has  been  crushed  by  the  displaced 
bone  at  the  time  of  the  accident,  but  that  there  is  no  continuing  pres- 
sure from  the  bone;  and  even  did  such  pressure  exist,  it  is  extremely 
improbable  that  relief  of  the  cord  from  it  would  in  any  way  promote 
recovery  of  function. 

It  is  argued  by  some  that  all  fractures  of  the  vertebrae  should  be 
treated  by  immediate  operation,  as  in  the  case  of  fractures  of  the 
cranium.  But  the  cases  are  not  similar;  for  in  fractures  of  the  cranium 
we  do  not  operate  to  repair  damage  to  the  brain  (which  is  irreparable), 
but  for  the  purpose  of  preventing  infection,  preventing  or  relieving 
intracranial  pressure  (from  effused  blood  or  displaced  bone),  or  pre- 
venting the  subsequent  development  of  Jacksonian  epilepsy.  In 
the  case  of  vertebral  fractures,  infection  is  very  little  to  be  feared, 
none  of  these  fractures  except  those  from  gunshot  wounds  being  com- 
pound; while  intraspinal  pressure,  in  the  sense  in  which  we  speak 
of  intracranial  pressure,  scarcely  exists,  save  in  the  rare  cases  of 
rapidly  ascending  paralysis  from  hematorrachis.  In  spinal  fractures, 
therefore,  operation  should  be  undertaken,  not  to  repair  irreparable 
damage  to  the  cord,  but  as  indicated  above  only  when  it  is  probable 
that  some  extramedullar  lesion  (displaced  bone,  blood-clot)  causing 
continuing  pressure  can  be  removed. 

Laminectomy. — The  patient  lies  prone.  A  skin-flap  is  turned 
aside,  exposing  the  spinous  processes,  and  the  muscles  are  detached 
by  blunt  dissection  from  the  laminae  of  one  side.  Hemorrhage, 
which  is  profuse,  is  really  controlled  by  gauze  pressure.  Hemostats 
are  useless.  The  laminae  of  the  other  side  are  then  cleared.  When 
the  requisite  number  of  arches  (usually  four  or  five)  have  been  thus 
exposed,  the  supraspinous  ligament  connecting  the  lower  spinous 
processes  is  divided,  and  a  large  bone  cutting  forceps,  with  blades 
angled  on  the  flat  (Fig.  712),  is  passed  into  the  opening  and  the  requisite 
number  of  spinous  processes  is  removed  from  below  upward.  A  crown 
trephine  is  then  employed  to  open  the  spinal  canal,  and  the  opening 
thus  made  is  enlarged  by  rongeur  forceps,  biting  away  the  laminae  as 
far  as  the  articular  processes.  This  method  is  quicker  and  safer  than 
the  use  of  chisel  and  mallet.  After  the  wound  has  been  made  dry,  the 
dura  is  opened  by  a  median  longitudinal  incision,  allowing  the  cerebro- 
spinal fluid  to  escape  slowly.    The  cord  is  inspected,  and  spicules  of 


64S 


SURGERY  OF   THE  SPINE 


bone,  blood-clot,  etc.,  may  then  be  removed.    Usually  it  is  not  possible 
to  tell  from  the  appearance  of  the  cord  whether  or  not  it  is  the  seat 


Fig.  712. — Largo  hour  cutting  forceps  for  laminectomy,  with  blades  angled  on 

the  flat. 


of  a  complete  transverse  lesion.    Some  days  or  weeks  after  the  injury 
the  cord,  above  and  below  the  lesion,  may  seem  swollen.    If  the  cord 

is  completely  severed,  attempts  should 
be  made  to  suture  it1  with  fine  chro- 
mic catgut,  introduced  as  mattress 
sutures  with  a  fine  curved  needle. 
The  dura  should  not  be  tightly  sutured 
and  the  wound  is  then  closed  in  layers 
without  drainage. 

Traumatic  Spondylitis  (Kiimmel, 
1S91). — Under  this  term  is  described 
a  rarefying  osteitis  of  the  vertebras, 
which  develops  after  severe  contusion 
or  fracture,  and  gives  rise  to  a  grad- 
ually increasing  kyphosis  (Fig.  713). 
Mauclaire  and  Burnier  (1912)  col- 
lected one  hundred  such  cases.  In 
spinal  injuries,  long  after-treatment 
(plaster  of  Paris  jackets,  body  braces) 
is  necessary  to  prevent  the  develop- 
ment of  such  a  deformity.  It  is 
treated  as  is  tuberculosis  of  the  spine. 
Osteomyelitis.  —  Osteomyelitis  of 
the  vertebrae  is  rare.  Symptoms  of 
general  sepsis  may  obscure  the  local 
affection,  so  that  this  may  not  be 
detected  until  abscesses  form,  unless 
symptoms  of  compression  of  the  spinal  roots  or  the  cord  sooner  call 
attention  to  the  vertebral  column.    The  mortality  is  about  60  per  cent. 

1  Harte  and  Stewart  (1902)  reported  a  case  of  suture  of  the  spinal  cord  after 
excision  of  the  damaged  area  (three-fourths  of  an  inch  in  extent),  caused  by  bullet 
wound;  there  was  return  of  fair  function  in  the  paralyzed  lower  limbs'.  A.  R. 
Allen  (1911^  suggested  immediate  median  longitudinal  section  (1  to  2  cm.) 
of  the  spinal  cord  in  the  area  believed  to  be  damaged,  on  the  theory  that  para- 
plegia results  from  secondary  compression  from  intramedullary  edema  rather  than 
from  actual  destruction  of  the  cord  tissue  by  the  original  injury. 


Fig.  713. — Traumatic  spondylitis. 
Elevator  descended  on  back  of  neck, 
causing  violent  flexion,  six  months 
before  photograph  was  made.  Epis- 
copal   Hospital. 


TUBERCULOSIS  OF   THE  SPINE  649 

The  affected  area  should  be  exposed;  almost  invariably  it  is  the 
vertebral  bodies  that  are  diseased.  The  cervical  spine  is  approached 
by  an  incision  posterior  to  the  sternomastoid,  the  thoracic  region 
by  an  operation  known  as  costo-transversectomy  (p.  661),  and  the 
lumbar  spine  by  the  retroperitoneal  route,  as  in  operations  on  the 
kidney.  The  abscess  is  evacuated,  and  sufficient  bone  is  removed  to 
secure  free  drainage.  If  recovery  ensues,  the  spine  must  be  supported 
as  in  convalescence  from  tuberculosis  of  the  vertebrae. 

Tuberculosis  of  the  Spine;  Pott's  Disease.1— More  than  one-third 
of  the  osseous  lesions  of  tuberculosis  are  located  in  the  vertebral 
column.  Children,  from  two  to  ten  years  of  age,  are  affected  oftenest, 
and  the  disease  is  comparatively  rare  in  adults.  Two-thirds  of  the 
cases  begin  in  children  under  five  years  of  age.  The  lesions  are  situated 
almost  exclusively  in  the  vertebral  bodies,  and  affect  the  thoracic 
vertebrae  oftenest  (over  50  per  cent,  of  cases),  and  the  cervical  region 
least  often  (about  15  per  cent.).  Destruction  of  the  vertebral  bodies 
by  caseous  softening,  with  continuance  of  weight-bearing  function, 
explains  the  development  of  various  deformities.  Cold  abscesses  are 
a  notable  feature  of  the  disease,  forming  its  most  important  complica- 
tion. Paraplegia,  much  less  frequent,  and  probably  no  more  serious 
in  its  results,  is  the  other  main  complication. 

Symptoms. — The  first  symptoms  to  attract  attention  may  be  mere 
listlessness,  a  desire  to  sit  still  and  to  hold  on  to  the  tables  and  chairs 
in  walking  around  the  room.  Usually  slight  alterations  in  the  gait, 
in  the  manner  of  stooping,  etc.,  are  observed  very  soon.  The  patient, 
like  Agag  in  the  presence  of  Samuel,  walks  "delicately,"  fearful  to 
make  any  sudden  movement  lest  the  spine  be  jarred.  The  body  may 
be  held  persistently  to  one  side.  In  trying  to  pick  anything  off  the 
floor,  instead  of  stooping  like  the  normal  child,  by  flexing  the  lumbar 
spine  and  the  pelvis,  the  patient  holds  the  spine  rigid  and  upright, 
and  by  flexing  his  knees  and  hips  brings  his  buttocks  almost  in  contact 
with  the  ground.  In  standing,  the  patient  may  lean  forward  and 
support  his  body  by  resting  his  hands  on  the  thighs;  in  sitting  he  will 
prop  himself  up  on  his  hands;  and  in  disease  of  the  cervical  region 
may  hold  the  chin  in  the  hands  and  turn  the  whole  body  around,  or 
merely  roll  his  eyes,  instead  of  turning  his  head.  At  night  the  child 
is  restless,  and  sleep  may  be  disturbed  by  starting  pains,  with  their 
attendant  night-cries  (p.  521).  "Belly-ache"  often  is  one  of  the 
earliest  complaints,  being  due  to  pain  referred  along  the  intercostal 
nerves.  Pain,  occasionally  is  referred  to  the  buttocks  or  the  knees, 
when  the  lumbar  spine  is  diseased. 

Physical  Examination,  thorough  and  systematic,  is  indicated  when- 
ever any  symptoms  point  to  a  possibility  of  spinal  disease.  Have 
all  the  patient's  clothing  removed,  and  let  him  walk  barefoot  to  and 
fro,  studying  the  gait  in  all  aspects.    Let  him  stoop  forward,  flexing 

1  Paraplegia  resulting  from  this  affection  was  first  carefully  studied  by  Percival 
Pott  in  1779. 


050 


SURGERY  OF  THE  SPINE 


the  lumbar  spine  and  pelvis,  but  keeping  the  knees  extended,  until 
the  tips  of  the  fingers  touch  the  floor.  Note  any  indications  of 
discomfort  so  produced,  and  especially  any  break  in  the  normal  con- 
tour of  the  flexed  spine,  which  should  be  one  continuous  curve.  Mus- 
cular spasm,  from  underlying  disease,  will  cause  loss  of  this  rounded 
contour,  and  the  process  of  straightening  up  again  may  be  attended 
by  jerky  movements.  Then  let  the  patient  sit  on  the  floor  or  on  a  firm 
couch,  and  bend  his  body  well  down  between  his  fully  flexed  thighs, 
so  as  to  flex  the  spine  as  far  as  possible;  and  note  any  irregularity  in 
the  contour.  Then  lay  the  patient  prone,  and  gently  elevate  the  feet 
in  one  hand,  thus  hyper-extending  the  spine  (Fig.  714).  Note  here 
also  any  area  which  lacks  normal  flexibility,  or  which  is  painful. 
Then  raise  the  head  and  shoulders  from  the  bed,  to  test  the  flexibility 
of  the  cervical  and  upper  thoracic  spine  in  the  same  manner. 


Fig.  714. — Examination  for  rigidity  of  spine  in  Pott's  disease:  the  patient  lies  prone 
and  the  spine  is  hyperextended  by  raising  the  feet.     Orthopaedic  Hospital. 


When  typical  deformity  once  has  appeared,  diagnosis  is  compara- 
tively easy.  But  earlier  types  of  deformity  should  be  recognized 
when  present.  In  the  cervical  spine,  wry-neck  may  often  be  symp- 
tomatic of  tuberculosis;  in  the  thoracic  region  a  posterior  angular 
curvature  (kyphosis)  is  nearly  pathognomonic;  and  in  the  lumbar 
region  an  exaggerated  lordosis,  with  protuberant  abdomen,  may  first 
attract  attention.  Lateral  deviation  of  the  spine  is  seen  chiefly  in 
disease  in  the  dorso-lumbar  or  lumbo-sacral  regions  (Fig.  715)  and  may 
be  due  to  unilateral  spasm  of  the  psoas,  from  incipient  cold  abscess. 
Careless  observation  may  mistake  this  deviation  for  lateral  curvature 
of  the  spine  (p.  573) ;  but  pain  usually  is  absent  in  the  latter  deformity, 
and  physical  examination  will  detect  neither  tenderness  (abscess?) 
nor  muscular  spasm.  In  cases  where  the  diagnosis  remains  doubtful, 
the  tuberculin  test  (p.  79)  may  be  tried;  and  under  any  circum- 
stances the  patient  should  be  kept  under  strict  observation  until 
further  development  of  symptoms  makes  the  diagnosis  certain. 


TUBERCULOSIS  OF  THE  SPINE 


651 


Deformity. — This  requires  further  discussion.  In  the  thoracic  region, 
as  already  noted,  the  deformity  is  characteristically  angular  and  sharp 
(Fig.  716) ;  as  the  disease  progresses  the  kyphos  becomes  more  rounded 
(Fig.  717).  In  children  it  is  rather  an  early  development,  and  rarely 
is  absent  after  the  lapse  of  a  few  months.  In  adults,  on  the  other  hand, 
as  the  vertebral  bodies  contain  much  more  calcareous  matter,  the 
disease  may  exist  for  many  months,  sometimes  for  years,  before  any 
noticeable  kyphos  develops.  In  low  lumbar  and  sacral  tuberculosis 
the  deformity  at  any  age  is  much  less  conspicuous  than  in  the  thoracic 
and  cervical  regions,  and  may  manifest  itself  only  in  a  stunting  of  the 


Fig.  715. — Pott's  disease,  showing  lateral 
deviation  to  left.  Age  thirteen  years.  Dura- 
tion seven  months.     Orthopaedic  Hospital. 


Fig.  716. — Pott's  disease.  Age  seven 
years.  Duration  one  year,  showing 
angular  kyphos.     Orthopaedic  Hospital. 


patient's  height  (Fig.  718).  In  the  cervical  and  lumbar  regions,  where 
lordosis  normally  exists,  the  disease  rarely  causes  more  than  an  obliter- 
ation of  this  anterior  concavity,  rendering  the  affected  spine  straight. 
When  a  kyphos  high  in  the  thoracic  region  is  well  marked,  a  com- 
pensatory lumbar  lordosis  may  develop,  giving  the  patient  a  strutting, 
self-important  air,  while  the  lower  ribs  may  be  elevated,  marked 
"chicken  breast"  developing  (Fig.  719).  In  lumbar  disease,  on  the 
contrary,  the  ribs  are  depressed,  and  the  outlet  of  the  pelvis  may  be 
much  contracted  antero-posteriorly,  owing  to  the  rotation  of  the 
sacrum  around  a  transverse  axis. 


652 


SURGERY  OF   THE  SPINE 


.  I  bscess. — As  the  disease  affects  almost  exclusively  the  bodies  of 
the  vertebra?,  any  cold  abscess  that  develops  will  be  found  beneath 
the  anterior  common  ligament.  This  structure  prevents  the  pus  from 
extending  forward,  with  the  result  that  it  gravitates  along  various 
planes  of  fascia,  and  comes  to  the  surface  in  rather  typical  locations. 
Only  in  the  rare  cases  of  disease  of  the  vertebral  arches  is  the  abscess 
apt  to  point  posteriorly,  and  then  usually  in  the  median  line. 

When  suppuration  occurs  in  disease  of  the  cervical  spine,  it  forms 
a  retro-pharyngeal  abscess;  this  may  cause  dysphagia,  dyspnea,  or 
even  alterations  in  the  voice  if  the  pus  sinks  so  far  as  to  compress  the 
larynx  or  distort  the  vagus  nerve  or  its  laryngeal  branches.    As  such 


Fig.  717. — Old  Pott's  disease,  age  six- 
teen years;  duration  since  three  months 
old,  showing  rounded  kyphos.  Ortho- 
paedic Hospital. 


Fig.  71S. — Old  Pott's  disease.  Age 
twelve  years;  duration  ten  years.  Show- 
ing stunting  of  patient's  height.  Ortho- 
paedic Hospital. 


an  abscess  increases  in  size,  it  may  rupture  into  the  pharynx  and  cause 
sudden  death  by  suffocation;  or,  as  is  much  more  usual,  may  make  its 
way  to  the  lateral  aspect  of  the  spine,  and  point  in  the  neck,  usually 
behind  the  sternomastoid  muscle  (Fig.  719) ;  rarely  it  may  follow  the 
cords  of  the  brachial  plexus  into  the  axilla.  In  the  lower  cervical  and 
upper  dorsal  regions,  the  abscess  bulges  into  the  posterior  mediastinum, 
and  may  track  along  the  aorta  and  external  iliac  artery  until  it  points 
below  Poupart's  ligament;  or,  as  is  less  usual,  may  track  outward 
along  the  ribs,  pointing  usually  near  their  angles,  and  simulating  costal 
caries  (p.  780).  In  the  lower  dorsal  and  lumbar  regions  the  pus  usually 
passes  beneath  the  internal  arcuate  ligament  of  the  diaphragm,  invades 


TUBERCULOSIS  OF  THE  SPINE 


653 


the  psoas  muscle  (psoas  abscess),  and  points  in  Scarpa's  triangle  on  the 
outer  side  of  the  femoral  vessels  (Fig.  720).  Usually  such  an  abscess 
may  be  detected  while  still  in  the  iliac  fossa.  Sometimes,  instead  of 
entering  the  psoas  sheath,  the  pus  passes  beneath  the  external  arcuate 
ligament,  and  points  in  the 
lumbar  region  (lumbar  abscess), 
simulating  a  perinephric  ab- 
scess (Fig.  721).  Very  occa- 
sionally an  abscess  may  leave 
the  pelvis  through  the  sacro- 
sciatic  notch  and  point  in  the 


Fig.  719. — Cervico-dorsal  Pott's 
disease  with  retropharyngeal  abscess. 
Age  twelve  years;  duration  of  disease 
ten  years.  Developed  dyspnea  and 
dysphagia;  and  sinus  formed  on  right 
side  of  neck  posterior  to  the  sterno- 
mastoid  muscle;  through  this  sinus 
liquid  food  has  been  discharged,  for 
the  last  six  months,  whenever  the 
patient  swallows.  Orthopaedic  Hos- 
pital. 


Fig.  720. — Psoas  abscess  from  Pott's 
disease.  Age  three  years;  Pott's  disease  for 
one  year;  abscess  for  several  months.  Or- 
thopaedic Hospital. 


Fig.  721. — Left  lumbar  abscess  in  Pott's 
disease.  Age  four  years;  Pott's  disease  for 
one  year;  abscess  several  months.  Abscess 
treated  by  operation,  as  advised  in  text. 
No  return  of  abscess,  and  patient  in  good 
health  five  years  after  operation.  Ortho- 
paedic Hospital. 


buttock  ((/luteal  abscess) ;  and  an  ischio-rectal  abscess  sometimes  may  be 
traced  to  the  spine. 

Diagnosis  of  Abscess. — These  various  forms  of  abscess  should  be 
watched  for.  Their  development  may  account  for  contractures 
(especially  of  the  psoas  muscle),  for  an  apparently  inexplicable  exacer- 


i;.-| 


SURGERY  OF   THE  SPINE 


bat  ion  of  symptoms  (pain,  fever,  disability),  and  very  occasionally 
(when  the  abscess  ruptures  into  the  spinal  canal)  for  suddenly  devel- 
oped paraplegia  or  meningitis. 


Fig.  722. — Early   psoas   contraction   from  left  psoas  abscess.     Age   eleven  years. 
Pott's  disease  for  four  years.     Abscess  for  eight  months.     Orthopaedic  Hospital. 


Fig.  723. — Pott's  disease  with  extreme  angulation,  but  not  sufficient  to  cause  para- 
plegia. Note  that  there  are  present  the  spines  of  fourteen  vetebra? — bodies  of  only  seven; 
in  other  words,  seven  bodies  have  been  destroyed.  From  a  specimen  in  the  Mutter 
Museum  of  the  College  of  Physicians  of  Philadelphia. 

Psoas  contraction  is  best  demonstrated  by  placing  the  child  on  its 
back,  with  its  lower  limbs  hanging  over  the  end  of  the  table:  the  normal 
limb  will  drop  below  the  horizontal,  while  one  with  psoas  contraction 
will  remain  flexed  at  the  hip,  in  spite  of  compensatory  lordosis  (Fig. 
722).    Or,  with  the  child  prone,  the  hip-joints  may  be  tested  for  hyper- 


TUBERCULOSIS  OF  THE  SPINE  655 

extension,  as  in  the  examination  for  coxalgia  (p.  534).  There  is  little 
difficulty  in  distinguishing  between  coxalgia  and  psoas  contraction 
secondary  to  Pott's  disease;  in  the  former,  the  motions  of  the  hip  are 
limited  in  all  directions,  not  only  in  extension;  and  there  are  no  evi- 
dences of  spinal  disease.  An  early  psoas  abscess  usually  is  palpable,  a 
distinct  fulness,  which  is  absent  on  the  normal  side,  being  present  along 
the  course  of  the  psoas  muscle.  Intraperitoneal  abscesses,  as  from 
appendicitis,  are  of  much  more  acute  development,  with  symptoms 
of  peritonitis,  and  are  attended  by  leukocytosis. 

Paraplegia  from  Pott's  disease  is  the  effect  of  pressure  on  the  spinal 
cord.  This  pressure  very  seldom  is  caused  by  bony  deformity  from 
extreme  angulation  (Fig.  723).  Almost  always  the  pressure  is  due  to 
tuberculous  granulation  tissue  extradural  in  situation.  Rarely  the 
rupture  of  a  cold  abscess  into  the  spinal  canal  will  cause  paraplegia, 
which  in  these  circumstances  generally  appears  suddenly.  In  most 
cases  the  paraplegia  is  slow  in  onset,  the  patients  first  becoming  spastic, 
and  only  gradually  losing  the  power  of  locomotion.  Sensation  is  not 
often  lost  entirely,  even  when  motion  is  entirely  abolished;  but  hyp- 
esthesia  and  paresthesia  are  frequent.  Complete  flaccid  paralysis  is 
rare.  Interference  with  the  functions  of  the  bladder  and  rectum  occurs 
as  in  fracture  dislocations  of  the  spine. 

Meningitis. — See  p.  623. 

Prognosis. — The  disease  is  seldom  cured;  in  adults  scarcely  ever. 
It  may  be  arrested  in  childhood,  and  many  a  "hump-back,"  even  with 
marked  deformity,  is  enabled  to  lead  for  years  an  active  and  useful 
life.  But  recurrence  of  symptoms  always  is  to  be  feared.  Very  few 
patients  die  as  a  direct  result  of  the  disease,  and  then  mostly  from 
complications,  such  as  tuberculous  meningitis  or  amyloid  degeneration 
of  the  viscera;  but  before  the  disease  becomes  latent  probably  one 
patient  out  of  every  three  affected  will  die  from  intercurrent  maladies 
which  would  have  been  survived,  had  not  the  viscera,  particularly 
the  heart  and  lungs,  been  so  distorted  by  the  spinal  deformity.  Neither 
an  unopened  abscess  nor  the  onset  of  paraplegia  seems  to  render  the 
prognosis  more  grave;  but  the  rupture  of  an  abscess,  with  the  secondary 
infection  which  this  may  entail,  opens  a  door,  as  Calot  says,  through 
which  death  soon  enters. 

Treatment. — To  secure  rest  for  the  diseased  spine  recumbent  treat- 
ment is  almost  indispensable,  and  in  the  acute  stages  is  imperative. 
This  at  once  removes  the  superincumbent  weight.  The  use  of  the 
Bradford  frame  (Fig.  560),  to  which  the  child  is  strapped,  largely  pre- 
vents motion  in  the  spine,  and  immobility  is  further  favored  by  head 
and  foot  extension  (Fig.  724) .  Meanwhile,  the  patient  should  be  kept 
in  the  open  air,  night  as  well  as  day  whenever  possible,  and  all  the 
general  measures  useful  in  surgical  tuberculosis  should  be  adopted 
(p.  80).  During  recumbency  it  is  especially  important  to  prevent 
"pointed-toe  deformity,"  which  is  very  apt  to  develop  if  the  foot  is 
unsupported  and  kept  constantly  in  the  equinus  position  by  the  weight 
of  the  bed-clothes.     Careful  trained  nursing  is  indispensable.     A 


<;:>.; 


SURGERY  OF   THE  SPINE 


nurse  trained  especially  in  this  work  is  desirable  whenever  her  services 
ran  he  obtained. 

If  recumbent  treatment  can  be  instituted  before  fixed  deformity 
develops,  it  may  be  possible  to  overcome  the  deformity  already  present, 
to  secure  arrest  of  the  disease,  and  to  prevent  the  occurrence  of  sub- 
sequent deformity.  As  in  the  case  of  tuberculous  coxitis,  the  only 
patients  I  have  seen  whom  I  could  consider  really  cured  of  the  disease, 
without  impairment  of  function,  were  those  in  whom  such  treatment 
was  adopted  before  the  diagnosis  was  entirely  certain.  When  once  a 
fixed  kyphos  has  developed,  it  is  very  seldom  that  surgery  can  do  any- 
thing better  than  to  prevent  increase  of  deformity. 


Fig.  724. — Extension  from  head  and  both  feet  for  Pott's  disease.     Orthopaedic 

Hospital. 


When  all  symptoms  of  the  disease  have  been  absent  for  two  or  three 
months  at  least,  ambulatory  treatment  may  be  tried  with  great 
caution,  and  never  without  efficient  support  to  the  spine.  The  plaster 
jacket,  when  properly  applied,  is  a  most  efficient  support.  It  may 
be  applied  with  the  patient  recumbent,  or  suspended  by  the  head 
and  shoulders,  the  heels  just  clearing  the  floor  (Fig.  725).  For 
most  cases  of  thoracic  and  lumbar  disease  the  prone  position  is 
preferable  (Fig.  726) :  the  child  lies  on  a  sling  attached  at  both  ends, 
by  a  bar  and  ratchet,  to  a  Bradford  frame;  the  sling  is  left  just  lax 
enough  to  allow  slight  hyperextension  of  the  spine,  and  is  included  in 
the  plaster  bandages,  being  slipped  out  after  the  plaster  jacket  has 
dried.  With  a  seamless  undershirt  next  the  skin,  and  all  bony  promi- 
nences (pelvis,  kyphos,  axillse)  well  padded  with  saddler's  felt,  such  a 


TUBERCULOSIS  OF   THE  SPINE 


657 


jacket  may  be  worn  for  several  months  in  comfort.  The  surgeon  should 
smell  the  cast  all  over  every  few  weeks,  and  thus  may  detect  very 
early  any  evidence  of  excoriation.  As  an  additional  guard  against 
such  an  occurrence,  "scratchers"  may  be  inserted  next  the  skin  before 
the  jacket  is  applied :  these  are  long  pieces  of  bandage,  with  their  pro- 
truding ends  sewed  to  each  other, 
and  are  to  be  drawn  up  and 
down  every  day  or  so,  to  keep  the 
skin  in  good  condition.  For  high 
dorsal  (above  the  eighth  thoracic 
vertebra)  or  cervical  disease  the 
head  and  neck  must  be  immobi- 
lized also;  and  in  such  cases  it  is 
more  convenient  to  apply  the 
jacket  with  the  patient  sus- 
pended. The  front  of  the  cast 
should  be  cut  away  to  diminish 
its  weight  (Fig.  727).  Celluloid 
jackets,  though  more  difficult  to 
construct,  are  lighter  than  those 
of  gypsum,  and  as  efficient. 

Braces. — These  depend  more 
on  fixation  (limitation  of  move- 
ment) than  on  support  in  the 
sense  of  relief  of  weight-bearing. 
Davis's  brace  (Fig.  728)  (1898) 

takes  a  fixed  point  of  support  at  the  pelvis  (between  iliac  crests  and 
great  trochanters)  by  means  of  a  malleable  steel  band ;  over  the  iliac 
crests  pass  well-padded  straps,  attached  behind  and  in  front  to  the 
pelvic  band,  which  effectually  prevent  the  brace  from  sliding  down- 
ward.   Up  from  the  pelvic  band   on  each   side  of  the  spine  runs  a 


Fig.  725. — Application  of  plaster  jacket 
with  patient  suspended.  Orthopaedic  Hos- 
pital. 


Fig.  726. — Position  for  applying  plaster  jacket  in  Pott's  disease. 

Hospital. 


Orthopaedic 


light  steel  bar,  connecting  through  a  cross-bar  above  with  crutch 
pieces  under  the  axillae;  these  are  supported  below  by  steels  attached 
to  the  pelvic  band  in  the  mid-axillary  line.  Nothing  passes  over  the 
shoulders,  as  the  object  is  not  to  hang  the  apparatus  from  the  shoulders, 
but  to  support  the  weakened  spine  from  below.  The  brace  is  thus 
42 


658 


SURGERY  OF  THE  SPINE 


fixed  below  at  the  pelvis  and  above  at  the  shoulders,  and  presses  for- 
ward on  the  transverse  processes  at  the  level  of  the  kyphos,  thus  tend- 
ing to  hyperextend  the  spine  and  relieve  pressure  on  the  bodies  of 
the  vertebrae.  If  the  lesion  is  above  the  eighth  thoracic  vertebra 
it  is  necessary  to  support  the  head  also,  by  an  attachment  to  the 
spinal  uprights.  When  ambulatory  treatment  is  first  commenced,  the 
apparatus  should  be  worn  at  night  as  well  as  during  the  day,  of 
course  being  removed  once  daily  for  bathing;  but  the  patient  never 


Fig.  727. — The  plaster  of  Paris 
jacket  for  upper  dorsal  disease. 
The  jacket  is  trimmed  away  above 
and  below,  and  the  large  abdominal 
window  is  cut  to  allow  free  breath- 
ing and  feeding.  (Cheyne  and 
Burghard.) 


Fig.  728. — Brace  for  cervical  or 
high  dorsal  Pott's  disease.  Ortho- 
paedic Hospital. 


should  be  in  any  other  than  the  recumbent  position  except  when  the  sjrinal 
support  is  in  place.  It  should  be  taken  off  only  after  he  lies  down  and 
should  be  put  on  again  before  he  even  sits  up. 

Some  support  of  this  kind  scarcely  ever  can  be  dispensed  with; 
when  it  is  abandoned  symptoms  nearly  invariably  return.  This  has 
been  demonstrated  to  be  a  fact  in  so  many  cases  that  it  is  almost 
foolhardy  for  a  surgeon  to  tell  a  patient  to  throw  away  his  braces 
and  go  without  support.  Only  after  many  long  months  of  freedom 
from  symptoms  is  it  desirable  to  dispense  with  the  crutch  pieces  of 


TUBERCULOSIS  OF   THE  SPINE 


659 


the  apparatus,  the  brace  then  consisting  merely  of  a  pelvic  band, 
spinal  uprights,  and  shoulder-straps  (C.  F.  Taylor's  brace,  1863).  Such 
an  apparatus  gives  practically  no  support,  but  prevents  dangerous 
degrees  of  movement  in  the  spine. 

Operative  fixation  of  the  spine,  in  recent  cases  of  Pott's  disease,  is  now 
a  recognized  method  of  treatment.  Albee  (1911)  splits  the  spinous 
processes  of  vertebrae  over  the  seat  of  disease  and  of  two  more  above  and 
below,  and  inserts  in  the  cleft  a  transplant  from  the  patient's  tibia  (Figs. 
729  to  731) ;  when  this  grows  fast,  firm  ankylosis  is  secured.  Hibbs  (1911) 
chisels  partly  through  the  spinous  processes  at  their  base,  turns  each  one 
down  until  it  comes  into  contact  with  the  base  of  the  spinous  process  next 
below,  and  thus  covers  the  diseased  region  of  the  spine  with  a  solid  bridge 


Fig.  729  Fig.  730 

Figs.  729  and  730. — Tuberculosis  of  vertebrae,  in  a  child  aged  four  years,  duration 
several  months.  Kyphos  disappeared  after  one  month's  recumbency.  Result  of  bone 
transplantation  shown  in  second  figure.     See  Fig.  731.     Episcopal  Hospital. 


of  bone.  I  believe  Albee's  operation  of  bone  transplantation  is  the  best 
except  in  adults  with  marked  deformity;  for  these  I  prefer  Hibbs's 
method.  After  operation  the  patient  is  confined  to  bed  for  about  six 
weeks,  and  is  then  allowed  to  be  about  with  a  light  brace,  which  usually 
may  be  discarded  in  the  course  of  a  few  months.  In  children  under 
six  years  the  operation  seldom  is  advisable,  and  in  older  patients  it 
does  not  always  arrest  either  the  local  disease  or  prevent  the  develop- 
ment of  a  kyphos  at  another  level.  I  have  seen  both  paraplegia  and 
abscess  develop  months  or  years  after  the  operation. 

Treatment  of  Abscess. — The  general  principles  which  should  guide 
surgeons  in  the  treatment  of  tuberculous  abscesses  and  sinuses  have 
been  discussed  in  Chapter  XV.     If  recumbency  and  immobility  do 


660 


SURGERY  OF   THE  SPINE 


not  cause  retrogression  of  the  abscess,  and  still  more  so  if  it  continues 
to  enlarge,  it  should  be  incised  through  healthy  overlying  tissues, 
should  be  carefully  evacuated,  its  cavity  should  be  thoroughly  wiped 
out  with  iodoform  gauze,  and  the  incision  should  be  tightly  closed  by 
several  layers  of  sutures  (see  Fig.  721).  A  retropharyngeal  abscess 
requires  early  evacuation,  to  prevent  rupture  into  the  pharynx  or 
secondary  infection  from  the  same  source.  In  adults  local  anesthesia 
is  sufficient.  An  incision  is  made,  in  the  lines  of  the  skin,  at  the  pos- 
terior border  of  the  sternomastoid  muscle,  and  this  is  defined  and 


Fig.  731. — Bone  transplant  in  lumbar  spine.     Episcopal  Hospital. 


drawn  forward;  usually  the  bulging  abscess  is  found  just  beneath  the 
muscle,  and  may  be  opened  by  Hilton's  method  (p.  50).  The  abscess 
wall,  the  muscle,  the  platysma,  and  the  skin,  should  be  sutured  if 
possible  in  separate  layers.  An  abscess  in  the  posterior  mediastinum 
rarely  requires  drainage;  it  is  exposed  by  excision  of  the  transverse  proc- 
esses of  the  diseased  vertebra?  with  the  heads  and  necks  of  the  corre- 
sponding ribs  (costo-transversectomy) .  These  are  approached  by  detach- 
ing the  spinal  muscles  from  one  side  of  the  spinal  gutter  (preferably 
on  the  right),  as  if  a  hemi-laminectomy  were  to  be  done  (Fig.  732). 
Injury  to  the  intercostal  nerves,  and  especially  to  the  pleura  should  be 


TUBERCULOSIS  OF  THE  SPINE 


661 


avoided.  A  psoas  abscess  still  within  the  abdomen  may  be  opened  by  a 
small  McBurney  muscle-splitting  incision  as  in  appendicitis  (p.  872), 
without  fear  of  invading  the  peritoneum  if  the  incision  is  made  close  to 
the  ilium  and  the  dissection  keeps  close  to  the  iliac  fossa.  After  evacua- 
tion, and  thorough  wiping  of 
the  abscess  walls  with  iodo- 
form gauze,  the  wall  of  the 
abscess  cavity  and  the  struc- 
tures of  the  abdominal  wall 
are  sutured  in  layers.  A 
2)soas  abscess  presenting  be- 
low Poupart's  ligament  does 
not  admit  of  such  secure 
closure,  but  the  abscess  wall, 
the  fascia  lata,  and  the  skin 
usually  can  be  closed  in 
separate  layers.  A  lumbar 
abscess  is  approached  as  in 
operations  on  the  kidney, 
and  usually  the  abscess  wall, 
the  lumbar  fascia,  and  the 
skin,  can  be  sutured  separ- 
ately. 

If  the  abscess  is  giving  no 
symptoms,  does  not  tend  to 
enlarge,  and  is  not  so  near 
the  skin  as  to  make  probable 
the  occurrence  of  secondary 
infection  from  skin  cocci,  it 

should  be  left  alone,  and  the  patient  should  be  treated  as  if  it  did  not 
exist.  Constant  watch,  however,  should  be  kept,  and  proper  treat- 
ment promptly  adopted  whenever  required. 

It  seems  unnecessary  to  add  anything  as  to  the  treatment  of  sinuses 
to  what  was  said  in  Chapter  XV. 

Treatment  of  Contractures. — Often  recumbent  treatment,  with 
weight  extension  applied  first  in  the  axis  of  the  deformity,  will  allow 
contractures  gradually  to  be  overcome.  Occasionally  tenotomies  are 
required  (adductors,  psoas,  rectus  femoris,  tensor  fascise  femoris,  ham- 
strings, tendo  Achillis,  etc.).  But  in  many  cases  which  have  been 
neglected,  sinuses  exist,  with  secondary  infection;  amyloid  degener- 
ation of  the  viscera  is  present;  and  nothing  remains  but  to  alleviate 
the  patient's  miserable  state  until  death  ends  the  scene  (Fig.  284). 

Treatment  of  Paraplegia. — In  almost  every  case  in  childhood  recum- 
bency will  cause  disappearance  of  paraplegia  in  the  course  of  six 
months  or  a  year.  In  such  cases,  then,  it  is  only  after  the  failure  of 
such  treatment  that  the  question  of  operation  need  be  raised.  In 
adults,  also,  recumbency  in  most  cases  will  cause  return  of  power 
within  that  time.    If  after  eight  months  or  a  year  of  recumbent  treat- 


Fig.  732. — Costo-transversectomy.  The  trans- 
verse processes  of  two  vertebra?  have  been 
excised,  and  the  lines  for  sectioning  two  others, 
as  well  as  the  ribs,  are  indicated. 


662  SURGERY  OF  THE  SPINE 

ment  in  adults  no  improvement  is  noticed  and  spasticity  still  persists, 
I  think  laminectomy  (p.  647)  should  be  done,  and  the  tuberculous 
granulation  tissue  excised;  the  dura  should  not  be  opened,  as  tuber- 
culous meningitis  probably  would  ensue;  and  it  is  quite  useless,  and 
perhaps  not  always  harmless,  to  curette  away  carious  bone  from  the 
vertebral  bodies.  Only  when  the  paraplegia  is  of  sudden  onset  do  I 
think  laminectomy  should  be  undertaken  as  an  early  operation. 
In  ordinary  cases  the  symptoms  come  on  very  gradually,  and  the 
ultimate  complete  or  nearly  complete  recovery,  even  after  many 
months  of  complete  abolition  of  the  motor  functions,  is  due  to  this 
very  feature,  as  the  cord  gradually  accustoms  itself  to  the  condition 
of  pressure.  But  when  the  onset  is  sudden  or  very  rapid  (complete 
paraplegia  developing  in  a  few  days  in  a  patient  previously  not  even 
spastic),  the  cord  has  not  the  time  to  so  accustom  itself,  and  there  is 
great  danger  that  it  may  be  damaged  irretrievably  unless  the  pressure 
is  promptly  relieved.  In  cases  with  such  rapid  onset,  as  already  noted, 
it  is  probable  that  the  cause  is  rupture  of  an  abscess  into  the  spinal 
canal. 

Other  Forms  of  Infectious  Spondylitis. — Typhoid  Spondylitis 
was  referred  to  at  p.  515.  When  a  patient  has  lain  long  in  bed,  with 
any  wasting  disease,  his  spine  is  apt  to  become  affected  from  static 
strain;  lying  flat  on  the  back,  the  normal  lumbar  lordosis  may  be 
lost,  and  the  thoracic  kyphosis  may  be  increased.  As  a  consequence, 
when  he  first  assumes  the  erect  posture,  or  even  during  convalescence 
in  bed,  complaints  of  stiff  back  may  be  made.  This  condition  is  not 
very  infrequent  after  long  and  serious  attacks  of  typhoid  fever,  but 
though  it  is  called  colloquially  by  the  name  of  "typhoid  spine,"  it 
should  not  be  confused  with  true  typhoid  spondylitis.  The  latter 
condition  is  much  rarer,  and  is  due,  as  suggested  in  18S9  by  Gibney, 
and  as  demonstrated  in  1906  by  McCrae,  to  definite  lesions  in  the 
vertebrae,  similar  to  those  occurring  in  the  long  bones  as  a  sequel  to 
typhoid  fever  (p.  467).  Only  a  few  vertebrae  are  involved,  usually 
in  the  lower  thoracic  or  lumbar  region.  The  onset  is  very  acute, 
resembling  the  most  severe  cases  of  Pott's  disease,  with  great  pain, 
which  may  radiate  along  the  spinal  nerves,  and  perhaps  with  cramps 
in  the  extremities.  Any  motion  is  painful.  Sometimes  a  kyphos 
develops.  Treatment  is  the  same  as  for  tuberculous  spondylitis; 
though  ankylosis  may  result,  recovery  usually  is  complete  in  a  few 
months. 

The  spine  may  be  affected  also  by  gonococcic  and  pneumococcic 
infection,  as  well  as  by  that  due  to  influenza,  tonsillitis,  etc.  The 
symptoms  are  subacute  in  onset,  are  typical  of  an  infectious  as 
distinguished  from  a  dystrophic  process  (p.  493);  and  the  diagnosis 
depends  on  the  recognition  elsewhere  in  the  body  of  the  original 
infective  focus.  According  to  Painter,  the  entire  vertebral  column, 
or  the  greater  part  of  it,  is  affected  at  once,  the  lesions  not  being  con- 
fined to  any  one  region,  as  is  so  frequently  the  case  in  hypertrophic 
arthritis  of  the  spine.    There  is  spinal  rigidity,  but  not  much  deformity, 


DYSTROPHIES  OF  THE  VERTEBRAL  COLUMN 


663 


unless  this  be  a  slight  lateral  deviation,  or  inclination  to  round 
shoulders.  From  involvement  of  the  costal  articulations,  respiration 
is  hampered.  Treatment  implies  cure  of  the  infecting  focus,  whenever 
this  can  be  discovered,  with  support  to  the  spine  during  the  period 
of  acute  symptoms,  and  counter-irritation,  massage,  and  gymnastics 
at  a  later  date.  The  spine  may  also  be  affected  by  what  were 
described  in  Chapter  XV  as  Acute  and  Chronic  Metastatic  Infections. 
(See  below.) 

Dystrophies  of  the  Vertebral  Column. — These  affections  conform 
more  or  less  closely  to  the  two  main  types  of  dystrophic  arthritis 
discussed  in  Chapter  XV.  The  term  Spondylitis  Deformans  is  quite 
as  indefinite  as  is  arthritis  deformans,  since  it  may  include  both  types, 
or  be  limited,  as  it  is  by  some,  to  the  hypertrophic  form.  According  to 
Poncet  and  Leriche,  as  noted  already  (p.  497),  these  affections  are  to 
be  classed  as  forms  of  tuberculous  rheumatism. 


Fig.  733.— Atrophic  arthritis  of 
spine ;  age  sixteen  years ;  duration  one 
year.  Fingers,  right  knee,  and  left 
shoulder  are  involved  also.  Ortho- 
paedic Hospital. 


Fig.  734. — Hypertrophic  spondylitis;  in- 
volvement also  of  acetabulum  and  pelvis. 
From  a  specimen  in  the  Mutter  Museum  of 
the  College  of  Physicians  of  Philadelphia. 


In  atrophic  spondylitis  the  vertebras  seldom  if  ever  are  affected  unless 
the  small  peripheral  joints  have  been  attacked  previously;  the  spinal 
changes,  therefore,  occur  merely  as  an  advanced  stage  of  atrophic 
arthritis  as  described  at  p.  493.    Fig.  733  depicts  the  typical  attitude 


664  SURGERY  OF  THE  SPINE 

assumed  by  these  patients.  Great  care  should  be  exercised  to  exclude 
any  infectious  origin  for  stiffness  of  the  spine,  before  presuming  to 
make  a  diagnosis  of  atrophic  spondylitis.  In  what  have  been  described 
as  the  subpyemic  and  cryptogenous  infections,  the  vertebral  column, 
when  affected,  seldom  presents  the  rounded  kyphosis  (Fig.  733)  which 
characterizes  the  dystrophic  conditions;  usually  it  becomes  abnormally 
straight,  and  the  patient  often  has  been  described  as  having  a  "  poker- 
back."  The  treatment  of  atrophic  spondylitis  has  been  discussed 
sufficiently  in  connection  with  atrophic  arthritis  (p.  497). 

In  hypertrophic  spondylitis,  the  spine  may  be  affected  alone,  or  in 
association  with  one  or  more  of  the  larger  joints  of  the  extremities. 
As  in  hypertrophic  arthritis  affecting  such  joints  alone,  so  in  the 
vertebral  disease,  a  history  of  previous  trauma  or  of  actual  static 
strain  usually  may  be  obtained.  As  a  rule  only  a  limited  portion  of  the 
vertebral  column  is  affected,  especially  the  lumbar  region,  frequently 
in  conjunction  with  hypertrophic  arthritis  of  the  sacro-iliac  or 
hip-joint  of  one  side.  The  pathological  changes  closely  resemble  those 
encountered  in  the  joints  of  the  limbs,  and  exostoses  or  osteophytes 
frequently  may  be  detected  in  skiagraphs.  Early  in  the  disease  there 
is  softening  of  the  vertebral  bodies  (rarefying  osteitis),  and  considerable 
deformity  may  occur,  in  the  form  of  a  more  or  less  rounded  kyphosis. 
As  the  affection  progresses,  however,  the  new-formed  periosteal  out- 
growths tend  to  cover  the  vertebral  bodies  with  a  more  or  less  con- 
tinuous bridge  of  bone,  rendering  the  spine  absolutely  immobile  (Fig. 
734).  Usually  this  bony  coating  is  situated  to  one  or  other  side  of  the 
median  line,  and  there  may  be  a  corresponding  lateral  deviation  of  the 
spinal  column.  If  any  of  the  spinal  nerves  are  compressed  there  may 
be  neuralgic  pains  in  the  parts  supplied,  and  sometimes  there  are 
secondary  muscular  atrophies.  This  complication  was  described  by 
Bechterew  (1892)  as  a  special  type  of  the  disease.  When  one  or 
more  of  the  "root  joints"  (i.  e.,  hip,  shoulder)  of  the  limbs  were 
involved  in  the  hypertrophic  changes,  the  affection  was  considered 
by  Marie  (1898)  a  separate  disease,  and  was  described  by  him  as 
"spondylose  rhizomelique."  In  many  cases  of  hypertrophic  spondy- 
litis the  affection  progresses  so  quietly  that  the  patients  never  apply 
for  treatment,  and  the  deformity  is  discovered  by  incident  or  only 
at  autopsy.  In  others,  pain,  stiffness,  and  considerable  disability 
demand  relief.  Treatment  is  to  be  conducted  as  in  cases  where  other 
joints  are  involved  in  hypertrophic  arthritis  (p.  501). 

Intraspinal  Tumors. — Usually  these  are  small,  more  or  less  encapsu- 
lated growths,  springing  from  the  meninges,  and  intradural  in  location 
nearly  as  often  as  extradural.  Very  rarely  has  an  intramedullary 
tumor  been  found.  In  most  of  the  reported  cases  the  tumors  were 
sarcomatous,  but  fibroma,  endothelioma,  echinococcus  cysts,  and  other 
growths  have  been  found;  and  it  is  not  unlikely  that  in  some  of  the 
cases  classed  as  sarcomatous  the  microscopical  diagnosis  was  in  error. 

Symptoms. — Pain  of  a  rheumatic  or  neuralgic  character,  localized 
to  one  limb  or  to  one  of  the  intercostal  nerves,  usually  is  the  first 


CHRONIC  SEROUS  SPINAL  MENINGITIS  665 

symptom  (root  irritation).  This  pain  may  subside  under  treatment 
but  is  prone  to  recur,  and  after  a  few  months  or  even  years  is  accom- 
panied by  a  numbness  or  heaviness  in  the  affected  extremity.  Though 
unilateral  at  first,  the  symptoms  nearly  invariably  become  bilateral 
before  complete  paralysis  develops.  The  ensuing  paraplegia  conforms 
to  the  ordinary  type  due  to  "pressure  myelitis;"  there  is  spasticity  at 
first,  but  later  complete  flaccidity  develops.  As  physical  signs  of  a 
tumor  (deformity,  rigidity  of  the  spinal  muscles,  tenderness)  usually 
are  absent,  the  diagnosis  depends  largely  on  the  history,  on  the  slowly 
developing  paralysis,  and  on  exclusion  of  other  forms  of  medullary 
compression.  A  neurological  consultation  is  desirable  to  aid  in  deter- 
mining the  spinal  segment  involved.  It  scarcely  ever  is  possible  to 
determine  before  operation  the  nature  of  the  tumor,  whether  or  not 
it  is  extradural,  or  even  whether  or  not  it  is  intramedullary. 

Treatment. — Immediate  resort  should  be  had  to  laminectomy  when 
once  the  diagnosis  is  reasonably  certain,  as  the  prognosis  is  absolutely 
bad  unless  pressure  on  the  cord  is  relieved.  The  usual  mistake,  on 
the  part  of  both  neurologists  and  surgeons,  has  been  to  expect  to  find 
the  tumor  at  too  low  a  level.  Hence  the  surgeon  should  expose  first 
that  region  of  the  cord  which  is  supposed  to  be  affected;  and  if  the 
growth  is  not  found  there,  he  should  search  upward  until  the  cause  of 
compression  is  found.  In  1905  I  collected  for  Harte  records  of  92 
operations  for  intraspinal  tumor;  in  only  5  of  these  cases  did  the 
surgeon  fail  to  find  the  tumor,  and  in  three  of  these  it  was  learned 
subsequently  that  it  was  situated  only  a  very  little  higher  than  the 
region  exposed  at  operation.  Elsberg  (1914)  pointed  out  that  in  some 
cases  where  an  intramedullary  or  subpial  tumor  cannot  be  removed 
at  the  primary  operation,  it  will  be  found  to  have  been  spontaneously 
extruded  a  few  days  later. 

The  mortality  of  the  operation  is  about  40  per  cent.  Of  185  patients 
who  survived,  one-third  were  classed  as  cured;  over  half  as  improved; 
and^in  only  10  per  cent,  was  no  improvement  secured  (Frazier,  1918). 

Chronic  Serous  Spinal  Meningitis  usually  is  a  complication  of 
chronic  serous  cerebral  meningitis  (p.  623),  but  may  occur  indepen- 
dently (Krause,  1906),  as  a  localized  collection  of  serous  fluid,  possibly 
the  result  of  a  previous  infection  which  has  caused  adhesion  of  the 
pia  to  the  dura  over  a  limited  area  (Spiller,  1906).  It  produces 
symptoms  closely  resembling  those  of  intraspinal  tumor,  and  the 
treatment  is  the  same. 


CHAPTER  XIX. 
SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK. 

SURGERY  OF  THE  NOSE. 

Epistaxis  or  Nosebleed  may  occur  spontaneously  or  from  trauma. 
Probably  many  cases  of  nosebleed  thought  to  be  spontaneous  really 
are  due  to  slight  trauma,  in  "blowing"  or  "picking"  the  nose. 
High  arterial  tension,  from  renal  or  cardiac  disease,  is  a  predisposing 
cause.  The  patient  should  lie  flat  with  the  head  slightly  elevated, 
and  should  refrain  from  blowing  the  nose.  It  should  not  be  thought 
that  hemorrhage  has  ceased  merely  because  no  blood  runs  out  of  the 
nostril,  since  the  patient  may  be  swallowing  the  blood  as  it  runs 
backward  into  the  pharynx.  Later  such  blood  may  be  vomited. 
Cold  applications  are  efficient  in  checking  the  hemorrhage  in  most 
cases.  Applying  a  small  roll  of  gauze  between  the  upper  lip  and  the 
alveolar  process,  in  the  midline,  and  compressing  the  lip  over  this  pad, 
sometimes  will  control  the  bleeding  by  pressure  on  the  coronary  vessels 
of  the  lip  or  the  arteria  septi  nasi.  In  almost  every  case  the  bleeding 
comes  from  this  artery  as  it  travels  upward  along  the  cartilaginous 
septum  just  within  the  nostril.  By  raising  the  tip  of  the  nose,  and  with 
light  reflected  from  a  head-mirror,  it  often  is  possible  to  see  this  bleed- 
ing-point, especially  if  the  nostril  is  sprayed  with  cocain  solution  (2  per 
cent.)  or  swabbed  with  adrenalin  (1  to  1000).  These  agents,  or  hydro- 
gen peroxide,  frequently  are  effective  in  checking  the  hemorrhage. 
If  bleeding  persists,  and  as  a  last  resort,  the  tampon  must  be  resorted 
to.  If  a  Simpson  splint  (made  of  Bernays's  sponge,  which  when  mois- 
tened swells  to  eight  times  its  previous  size)  is  available,  it  may  be 
inserted  within  the  nostril,  and  usually  is  very  efficient.  If  bleeding 
occurs  from  further  back  in  the  nostril,  it  may  be  necessary  to  plug 
the  posterior  as  well  as  the  anterior  nares.  This  is  done  by  attaching 
a  string  to  the  end  of  a  soft  rubber  catheter,  and  passing  this  (string 
end  first)  along  the  floor  of  the  nostril  until  the  catheter  emerges  in  the 
pharynx;  the  string  is  then  pulled  out  through  the  mouth,  and  is  tied 
to  a  tampon  of  size  sufficient  to  plug  the  posterior  naris  of  the  bleed- 
ing side  (Fig.  735).  As  the  catheter  is  withdrawn  from  the  nose  this 
tampon  is  pulled  by  the  string  into  the  mouth,  around  the  posterior 
margin  of  the  soft  palate  and  into  the  posterior  nasal  opening.  An 
end  of  string  is  left  long,  hanging  from  the  mouth,  to  facilitate  with- 
drawal. The  anterior  naris  is  then  plugged  from  the  front.  These 
tampons  should  not  be  left  in  place  more  than  twenty-four  or  thirty- 
six  hours,  as  they  are  apt  to  excite  suppuration,  and  perhaps  maxillary 
or  frontal  sinusitis,  or  even  otitis  media.  A  cannula  expressly  for  plug- 
(666) 


SURGERY  OF  THE  NOSE 


667 


Fig. 


Plugging  the  posterior  nares. 


ging  the  posterior  nares  was  invented  by  Bellocq,  and  is  useful  if  at 
hand. 

Foreign  Bodies  in  the  Nose  usually  may  be  extracted  by  fine  for- 
ceps or  scoop,  under  good  illumination.  If,  however,  the  foreign 
body  lie  not  on  the  floor  of  the 
nose,  nor  anteriorly,  it  will  be 
easier  and  safer  to  dislodge  it  by 
syringing  warm  boric  acid  or  saline 
solution  through  each  nostril  alter- 
nately. 

Acne  Rosacea. — Acne  rosacea 
in  its  early  stages  comes  under 
the  care  of  the  dermatologist ;  but 
when  through  long  duration  and 
neglect  of  proper  treatment  the  skin 
and  subcutaneous  tissues  of  the 
nose  have  become  hypertrophied 
(Acne  Hypertrophiea,  Rhinophyma) , 

then  surgical  treatment  is  necessary  for  a  cure.  The  nose  is  now 
enlarged,  erythematous,  covered  with  dilated  venules  or  arterioles; 
and  nodules  of  various  sizes  and  shapes  make  the  patient  conspicuous. 

Treatment:  Frequent  steaming  of  the  parts,  after  application  of 
green  soap  or  a  soap  poultice,  or  ointments  containing  sulphur  or 
salicylic  acid,  may  somewhat  improve  the  nutrition  of  the  skin;  but 
in  most  cases  the  over-growths  require  to  be  removed.  Simply  shaving 
oft'  these  excrescences  may  suffice,  the  denuded  areas  being  left  to  heal 
by  granulation;  or  excision  may  be  done,  and  the  wound  covered  with 
Wolfe  skin  grafts. 

Rhinoplasty. — The  formation  of  a  new  nose,  wholly  or  in  part,  may 
be  required  for  various  reasons.  The  deformity  known  as  Saddle  Nose 
(Fig.  1027),  occurring  as  the  result  of  syphilis,  old  fracture,  or  other 
lesion,  maybe  remedied  by  implantingbeneath  the  skin  a  suitably  shaped 
bridge  of  bone  or  cartilage.  Subcutaneous  injections  of  paraffin  have 
also  been  employed.  Kolle  (1908)  uses  paraffin  with  a  melting-point  of 
102°  to  115°  F.,  and  makes  the  injections  (by  means  of  a  special  syringe 
with  a  screw  piston)  with  the  paraffin  cold;  this  obviates  danger  of 
embolism.  No  anesthetic  is  required  if  the  injection  is  made  slowly, 
and  if  only  a  small  quantity  is  injected  at  any  one  time. 

If  the  nose  is  completely  destroyed  from  injury,  lupus,  syphilis, 
etc.,  a  new  one  may  be  constructed  by  plastic  operations.  In  the 
Indian  method  of  rhinoplasty,  used  by  the  native  surgeons  of  India 
for  many  centuries,  and  introduced  into  England  in  1816  by  Carpue, 
a  flap  is  taken  from  the  forehead,  and  is  twisted  around  a  pedicle 
which  contains  the  angular,  frontal,  and  supraorbital  arteries  of  one 
side  (Fig.  736).  The  flap  is  made  0.5  cm.  larger  on  all  sides  than 
desired,  as  it  is  sure  to  shrink.  The  edges  of  the  nasal  opening  are 
then  freshened,  and  all  bleeding  is  controlled  by  very  fine  catgut  liga- 
tures.   The  frontal  flap  is  then  rotated  and  is  sutured  in  place.      A 


60S 


SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 


columna  may  be  formed  from  the  upper  lip,  if  thought  desirable,  after 
a  week  or  ten  days,  but  usually  the  orifice  of  the  new  nose  contracts  so 
much  that  it  is  undesirable  to  subdivide  it.     The  pedicle  is  not  cut 

through  for  about  a  month 
after  the  primary  operation. 
The  denuded  frontal  area 
may  be  left  to  heal  by  gran- 
ulation or  may  be  covered 
by  Wolfe  grafts.  The  Italian 
Method  of  Rhinoplasty,  wide- 
ly employed  by  Taliacotius 
in  the  sixteenth  century, 
consists  in  transferring  a  flap 
from  the  arm.  At  the  first 
operation  the  flap  is  marked 
out  and  is  partially  de- 
tached ;  when  it  is  sufficiently 
vascularized  and  thickened, 
after  the  lapse  of  about  ten 
days,  this  flap  is  stitched  to 
the  freshened  edges  of  the  remaining  nasal  structures,  and  the  arm  and 
head  are  securely  bandaged  together.  A  plaster-of-Paris  dressing  is 
desirable.    About  ten  days  or  two  weeks  later  the  flap  is  cut  away  from 


Fig.  73G. — Outline  of  frontal  flap  for  rhino- 
plasty by  the  Indian  method. 


V 

1 

1 

1 

i 

jf 

L     .. 

w 

«S 

m : , 

Fig.  737. — Patient  with  destruction  of 
the  nose.  Before  rhinoplasty.  (See  Fig. 
738.) 


Fig.  738. — Same  patient  after  rhino- 
plasty by  the  Indian  method  by  the  late 
Prof.  Ashhurst,  1894.  University  Hos- 
pital. 


the  arm;  and  a  columna  may  be  formed  then,  or  subsequently.  In  all 
modern  operations  for  rhinoplasty  (Keegan,  Gillies,  1919)  a  skin  lining 
for  the  new  nose  is  formed  by  inverting  flaps  which  are  subsequently 


SURGERY  OF  THE  CHEEKS 


669 


covered  by  other  skin  flaps.  Gillies  often  uses  flaps  attached  by 
tubulized  pedicles  which  contain  the  temporal  artery;  after  the  new 
nose  has  grown  in  place,  the  pedicles  of  the  flaps  are  cut  and  restored 
to  the  forehead. 

SURGERY  OF  THE  CHEEKS. 

Keratosis  Senilis  or  Seborrheic  Patch  has  been  referred  to  in  Chap- 
ter IV  as  a  precancerous  condition  of  the  skin.  The  skin  of  the  face 
of  elderly  persons,  especially  those  who  have  been  exposed  much  to 
the  weather,  may  present  a  number  of  slightly  raised,  greasy,  yellow- 
ish-brown patches,  due  to  hypertrophy  of  the  epidermal  cells,  and 
accumulation  of  sebaceous  matter  on  the  surface.     If  these  patches 


Fig.  739. — Hotchkiss  method  of  meloplasty.     Episcopal  Hospital. 

are  picked  off  and  a  small  bleeding  erosion  is  revealed,  this  lesion 
probably  is  a  superficial  epithelioma;  if  no  bleeding  occurs  the  lesion 
may  still  be  in  its  precancerous  stage.  Beyond  recognizing  this  fact 
and  acknowledging  the  possibility  that  proper  treatment  by  a  skilled 
dermatologist  might  prevent  or  at  least  delay  the  development  of 
epithelioma,  neither  pathologist  nor  clinician  can  go.  Before  there  is 
any  suspicion  of  malignancy,  careful  treatment  of  the  skin  should  be 
adopted.  The  face  should  be  well  steamed  over  a  bucket  of  hot 
water,  at  least  once  daily;  after  thoroughly  drying,  a  little  salicylic 
acid  ointment  (10  grains  to  the  ounce)  should  be  rubbed  into  the 
seborrheic  patches.  Sometimes  green  soap  (Tinctura  Saponis  Viridis, 
U.  S.  P.)  should  be  used  instead  of  ordinary  toilet  soap.    D.  W.  Mont- 


G70  SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 

gomery,  who  has  studied  these  cases  most  carefully,  wipes  off  the  skin 
with  glacial  acetic  acid,  ami  in  rebellious  cases  uses  trichloracetic 
acid,  after  curetting  the  lesion;  then  the  arrays  are  employed.  He 
points  out  that  when  the  cheeks  or  other  portions  of  the  face  are 
widely  affected  radical  excision  is  not  to  be  considered  even  if  the 
epitheliomatous  nature  of  the  lesions  is  recognized;  and  any  flaps 
used  to  repair  defects  left  by  partial  excision  will  themselves  be  the 
seat  of  these  precancerous  growths,  which  will  in  time  develop  into 
epithelioma,  causing  an  apparent  local  recurrence.  If  only  one  or 
two  patches  exist,  they  should  be  treated  by  excision,  as  in  fully 
developed  epithelioma. 


Fig.  740. — Patient,  aged  fifty-seven  years,  four  days  after  operation  according  to  the 
method  of  Hotchkiss  (Figs.  739,  741  and  742),  for  carcinoma  of  cheek  (Plate  viii). 
Death  from  secondary  hemorrhage  fifteen  days  after  operation.     Episcopal  Hospital. 

Superficial  Epithelioma  or  Rodent  Ulcer  occurs  more  often  on  the 
cheeks  or  forehead  than  any  other  part  of  the  face,  especially  near  the 
ala  nasi,  on  the  lower  eyelid,  or  near  the  angle  of  the  mouth.  Some 
authorities  claim  that  it  owes  its  comparatively  benign  character 
to  the  poverty  of  these  areas  in  lymphatic  vessels.  Its  pathology  and 
clinical  course  have  been  discussed  in  connection  with  tumors  (p.  124). 
The  question  of  diagnosis  is  important.  It  must  be  distinguished 
from  deep-seated  epithelioma,  lupus,  and  syphilis.  Deep-seated 
epithelioma  rarely  occurs  on  the  face  except  on  the  lower  lip;  it 
may  develop  from  a  seborrheic  patch,  but  it  is  much  more  rapid  in 
growth  than  the  superficial  form  (months  instead  of  years),  and 
invades  the  regional  lymph  nodes.  Lupus  usually  affects  young  adult 
patients  of  scrofulous  diathesis;  it  is  very  rare  in  those  past  middle 
life  in  whom  epithelioma  is  common;  it  almost  always  presents  evi- 
dence of  having  healed  at  some  part,  which  is  rarely  the  case  in  epithe- 


SURGERY  OF  THE  CHEEKS 


671 


lioma;  and  the  typical  apple-jelly  nodules  usually  can  be  discovered 
around  the  periphery  of  the  ulcerated  areas  (p.  294).  The  facial  lesions 
of  syphilis,  especially  ulcerated  gummas,  sometimes    are    mistaken 


Fig.  741. — Von  Eiselsberg's  method  of  splitting  the  tongue  to  restore 
defect  in  cheek.     See  Figs.  739,  740  and  742. 

for  epithelioma;  but  the  previous  history  of  the  patient,  the  presence 
of  syphilitic  lesions  or  their  traces  elsewhere  in  the  body,  the  cir- 


Fig.  742. — Von  Eiselsberg's  method  of  restoring  a  defect  in  the  cheek  by 
splitting  the  tongue.     See  Figs.  739,  740,  and  741. 

cinate  or  reniform  shape  of  the  ulcers,  their  greater  depth  and  much 
more  rapid  extension,  as  well  as  the  result  of  antisyphilitic  remedies, 
and  the  presence  of  the  Wasserman  reaction,  will  render  the  correct 


672  SURGERY  OF  THE  FACE,   MOUTH,   AND  NECK 

diagnosis  evident.  It  should  not  be  forgotten,  however,  that  malig- 
nant changes  may  develop  in  old  syphilitic  or  lupous  ulcers. 

Treatment. — Treatment  of  rodent  ulcer  consists  in  excision  of  the 
entire  thickness  of  the  cheek  down  to  mucous  membrane  or  bone. 
The  wound  is  then  repaired  by  sliding  flap  as  indicated  in  Fig.  19G,  or 
by  Wolfe  grafts.  The  operation  of  repairing  a  defect  in  the  cheek  is 
known  as  mehplasty. 

Carcinoma  of  Buccal  Surface  of  Cheek. — This  is  an  unusual  but 
serious  situation  for  cancer  (Plate  VIII).  The  best  method  of  excision 
is  that  described  by  Hotchkiss  (1908),  which  is  sufficiently  indicated 
by  Figs.  739  and  740.  The  cervical  lymphatics  are  first  excised  in  one 
mass,  the  external  carotid  artery  being  ligated;  and  the  mucous  surface 
of  the  cheek  is  restored,  after  extraction  of  teeth  if  necessary,  by  von 
Eiselsberg's  method  (1906)  of  splitting  the  tongue  (Figs.  741  and  742). 

SURGERY  OF  THE  SALIVARY  GLANDS. 

Infectious  Parotitis,  called  also  symptomatic  parotitis,  and  parotid 
bubo,  is  an  acute  bacterial  infection  of  the  parotid  gland  occurring  in 
the  course  of  some  general  infection  (typhoid  fever,  scarlatina,  pyemia, 
etc.).  In  rare  cases  the  submaxillary  or  sublingual  glands  are  similarly 
affected.  In  contradistinction  to  epidemic  parotitis  (mumps),  only 
one  parotid  usually  is  affected,  and  suppuration  is  frequent.  Cases 
of  this  nature  may  also  follow  abdominal  or  other  operations,  but 
rarely,  if  ever,  unless  general  anesthesia  has  been  induced.  In  all 
such  instances,  as  in  typhoid  fever  and  other  wasting  diseases,  there 
is  abundant  opportunity  for  a  direct  ascending  infection  from  the 
mouth  along  Stenson's  duct;  and  while  infection  through  the  blood- 
stream cannot  be  denied,  it  probably  is  rare.  In  the  substance  of  the 
parotid  gland,  between  its  lobules,  there  are  numerous  minute  lymph 
nodes;  and  it  is  possible  that  some  cases  classed  as  parotitis  really  are 
instances  of  lymphadenitis  of  these  nodes.  Prophylaxis  is  important, 
and  consists  in  measures  to  promote  cleanliness  of  the  mouth  and 
prevent  drying  of  the  mucosa  around  the  orifice  of  the  parotid  duct. 
Mechanical  injury  of  the  glands  should  be  avoided  during  anesthe- 
tization. 

Treatment. — Local  applications  (ice  bag,  painting  with  iodin,  mouth 
washes)  may  be  useful  before  suppuration  occurs.  This  should  be 
treated  promptly  by  incision  parallel  with  the  branches  of  the  facial 
nerve.  A  probe  is  then  inserted,  and  an  endeavor  made  to  secure 
drainage  of  all  pockets  of  pus  through  the  one  opening;  but  owing  to 
the  dense  fibrous  stroma  of  the  gland  each  suppurating  lobule  may 
have  to  be  incised  separately. 

Tuberculosis  sometimes  attacks  the  parotid  lymph  nodes,  but  very 
rarely  affects  the  gland  itself.  Excision  of  these  nodes  is  difficult 
without  injuring  the  facial  nerve. 

Tumors  of  the  Parotid.- — The  peculiarity  of  parotid  tumors  is  that 
they  usually  are  of  the  "mixed"  variety  (p.  106).    This  may  be  due 


PLATE    VIII 


Carcinoma  of  Buccal  Surface  of  Right  Cheek. 

In  December,  1915,  he  noticed  a  white  spot  where  he  carried  his  quid  of  tobacco.  This 
spot  ulcerated  in  February,  1916.  Operation  in  August,  1916  (Fig.  740).  Above  is  seen 
the  cheek,  with  fibers  of  masseter  at  right.  Below  is  mass  of  cervical  lymph  nodes. 
Episcopal  Hospital. 


SURGERY  OF  THE  SALIVARY  GLANDS 


673 


to  the  situation  of  the  parotid  in  the  region  of  the  first  branchial  cleft 
of  fetal  life.  These  tumos  are  very  apt  to  contain  cartilage,  with 
areas  of  myxomatous  degeneration;  rarely  cysts  may  form.  They 
occur  in  young  adults,  and  grow  with  extreme  slowness;  often  no 
change  is  appreciable  from  year  to  year  (Fig.  743) .  At  first  they  are 
fairly  well  encapsulated,  but  owing  to  the  deep  relations  of  portions 
of  the  parotid  gland,  they  appear  to  be  fixed  at  an  early  stage  of 
development.  Though  the  tumor  may  grow  to  an  immense  size,  the 
facial  nerve  seldom  is  affected;  but  the  lobe  of  the  ear  becomes  dis- 
placed, outward  and  upward.  If  rapid  growth  develops,  as  it  usually 
does  in  time,  malignancy  should  be  suspected  (Fig.  744).  In  every 
advanced  cases,  secondary  enlargement  of  the  cervical  lymph  nodes 
may  occur.  Similar  growths  may  occur  in  the  submaxillary  salivary 
glands,  but  are  much  rarer,  and  seldom  are  distinctly  cartilaginous. 


Fig.  743. — Mixed  tumor  of  parotid,  age 
forty-two  years;  duration  twenty-two 
years.  Very_  slow  growth.  Patient  de- 
clined operation.     Episcopal  Hospital. 


Fig.  744. — Mixed  tumor  of  parotid 
(sarcomatous) ;  twenty-one  years'  dura- 
tion. Weight  of  tumor  two  pounds.  Re- 
moved by  the  late  Prof.  Ashhurst,  1896. 
University  Hospital. 


Treatment. — If  the  patient  is  seen  before  the  tumor  is  large,  and 
before  rapid  growth  has  commenced,  it  often  is  possible  to  enucleate 
the  growth  from  the  substance  of  the  parotid  without  injury  to  the 
facial  nerve  or  Stenson's  duct.  Operation  should  be  urged  before  the 
tumor  grows  very  large.  The  incision  should  be  made  parallel  with 
the  branches  of  the  facial  nerve,  nearly  as  high  as  the  zygoma,  and 
the  knife  should  pass  at  once  to  the  tumor,  with  no  dissection  of  the 
superficial  structures,  as  this  is  apt  to  injure  the  facial  nerve.  The 
growth  is  then  enucleated,  and  the  wound  closed  by  buried  and  super- 
ficial sutures.  In  malignant  cases  wide-sweeping  excision  must  be 
practised  if  any  operation  is  undertaken,  but  an  attempt  should  be 
made  to  preserve  the  facial  nerve  by  exposing  its  main  trunk  before 
it  enters  the  tumor.  Preliminary  ligation  of  the  external  carotid 
43 


674  SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 

artery  is  advantageous.  Blunt  dissection  should  be  avoided.  The 
parts  should  be  freely  exposed,  and  nothing  should  be  cut  that 
cannot  be  seen.  The  operation  is  tedious,  difficult,  and  dangerous. 
If  the  tumor  extends  far  into  the  retro-maxillary  fossa  and  appears 
densely  adherent  there,  as  ascertained  by  preliminary  examination 
through  the  mouth,  usually  no  operation  should  be  done.  (See  also 
remarks  on  Excision  of  Tumors,  p.  132). 

Mikulicz's  Disease  (1892)  is  a  rare  affection  characterized  by  pain- 
less, slowly  developing,  chronic,  symmetrical  enlargement  of  the 
parotid  and  lachrymal  glands;  sometimes  the  submaxillary  and  sub- 
lingual glands  are  involved  also.  In  some  cases  there  is  general  lym- 
phatic involvement  and  enlargement  of  the  spleen.  There  may  be 
fever.  If  such  constitutional  remedies  as  arsenic  and  iodide  of  potash 
are  ineffectual,  extirpation  may  be  justifiable  for  cosmetic  reasons, 
or  to  relieve  pressure  on  neighboring  structures.  The  cause  of  the 
disease  is  unknown. 

Salivary  Fistula. — This  usually  arises  in  the  parotid  gland,  especi- 
ally in  its  main  duct,  as  the  result  of  injury  (operative  or  accidental) 
or  suppuration.  The  secretion  discharges  on  the  cheek  which  is  kept 
constantly  moist,  especially  while  food  is  being  masticated.  The  skin 
may  become  very  much  irritated.  The  mouth  feels  dry.  The  patient 
is  rendered  both  conspicuous  and  miserable. 

Treatment. — If  the  orifice  is  in  front  of  the  masseter  muscle  the 
fistula  is  not  so  difficult  to  cure.  A  cannula  may  be  passed  from  the 
mucous  surface  of  the  cheek  through  the  fistula  on  to  the  cheek,  making 
two  punctures  of  the  mucosa,  about  one  centimeter  apart;  a  fine  wire 
(of  silver,  iron,  or  bronze-aluminum)  is  then  passed  through  these  two 
artificially  made  mucous  orifices  (Fig.  745),  and  is  tied  on  the  mucous 
surface  (Fig.  746).  The  edges  of  the  cutaneous  orifice  are  then  fresh- 
ened, and  it  is  closed  by  suture.  The  parotid  secretions  then  find 
their  way  along  the  wire  to  the  mouth,  and  by  the  time  the  wire  cuts 

out  and  establishes  an  internal 
opening  the  cutaneous  orifice  has 
healed.  If  the  fistula  is  situated 
over  the  masseter  muscle,  at- 
tempts should  be  made  to  con- 
struct a  channel  forward  in  the 
cheek  to  its  anterior  edge,  either 

^W^^^SA^lLsH';/     Salivary  duct 


-^.Mucosa 


Cutaneous  opening  of  fistula. 

Fig.  745. — Operation  for  salivary  fistula: 

both  ends  of  a  wire  are   conducted  to  the  Fig.  746.— Operation    for   salivary   fis- 

raucous  surface  of  the  cheek  through  punc-  tula:  the  wire  is  tied  on  the  mucous  sur- 

ture  made  by  a  cannula.  face. 

by  establishing  a  seton,  as  in  the  method  just  described,  or  by  a 
formal  plastic  operation.   Occasionally  partial  excision  of  the  parotid 


SURGERY  OF  THE  EAR 


675 


gland  will  be  necessary  to  cause  cessation  of  discharge.  If  no  infection 
is  present,  simple  ligation  of  the  main  duct  on  the  central  side  of 
the  fistula  may  result  in  atrophy  of 
the  gland. 

Sialo-lithiasis  or  Salivary  Calculus 
is  not  a  very  uncommon  condition.  In 
1908  Bendixen  referred  to  216  cases. 
The  calculous  formation  is  due  to 
bacterial  action  on  the  secretion  of  the 
glands,  as  in  the  pathogenesis  of  biliary 
calculi.  The  calculus  usually  obstructs 
the  excretory  duct,  causing  secondary 
enlargement  of  the  glands,  with  mild 
inflammatory  symptoms.  Occasionally 
recurrent  attacks  of  colic  occur.  The 
affection  is  much  more  common  in  the 
submaxillary  than  in  either  the  parotid 
or  sublingual  gland.  Often  the  calcu- 
lus is  palpable  in  the  floor  of  the 
mouth,  just  beneath  the  mucosa. 
Treatment  consists  in  removal  of  the 
stone  by  incision  in  the  floor  of  the 
mouth;  if  the  calculus  is  in  the  body 
of  the  gland,  and  especially  if  there  is  suppuration  or  a  cutaneous 
fistula,  it  is  better  to  excise  the  entire  gland,  by  an  incision  beneath 
the  mandible. 

Chronic  Inflammation  may  affect  the  submaxillary  and  sublingual 
salivary  glands.  The  affection  may  simulate  a  neoplasm  in  its  gradual 
onset  and  indolent  course.  Usually  the  glands  are  found  to  contain 
minute  abscesses,  and  there  is  increase  in  the  connective  tissue.  Extir- 
pation is  the  proper  treatment  (Fig.  747) . 


■ 

■  •' 

g£ 

1    /&> 

,^> 

A-      ^M 

wk    * 

£%. 

.-  i* 

* 

Fig.  747. — Chronic  inflammation 
of  submaxillary  and  sublingual  sali- 
vary glands  and  of  submaxillary 
lymph  nodes.     Episcopal  Hospital. 


SURGERY  OF  THE  EAR. 
Foreign  Bodies. — It  is  necessary  first  to  ascertain  whether  or  not  the 
foreign  body  still  is  present.  In  children  the  history  is  not  always  very 
clear,  and  much  harm  may  be  done  by  incautious  exploration.  If  a 
probe  or  forceps  is  pushed  blindly  along  the  canal,  the  foreign  body 
may  be  driven  further  in.  Under  good  illumination  from  a  head-mirror, 
and  by  drawing  the  pinna  upward  and  backward  to  straighten  the 
external  auditory  canal,  the  surgeon  will  be  able  to  detect  the  presence 
of  a  foreign  body  (Fig.  748).  In  children  the  use  of  an  ear  speculum 
seldom  is  necessary,  but  where  the  canal  is  hairy,  as  in  many  adults, 
this  is  indispensable.  In  most  cases  persistent  syringing  with  warm 
sterile  saline  solution  or  weak  antiseptic  will  be  successful  in  remov- 
ing the  foreign  body;  but  if  this  is  a  pea  or  bean  the  soaking  may 
cause  it  to  swell  up  and  thus  render  its  removal  more  difficult.  For 
such  bodies,  therefore,  and  for  all  others  where  syringing  has  failed, 
delicate  forceps  or  scoop  should  be  employed.  The  same  methods 
should  be  employed  in  cases  of  impacted  cerumen. 


67G 


SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 


Furuncle.  Furuncle  of  the  auditory  canal  is  an  exceedingly  painful 
condition  which  requires  prompt  incision.  Even  though  the  sharpest 
knife  is  used,  and  the  incision  made  with  great  delicacy,  the  pain  is 
excruciating,  but  if  the  auriculo-temporal  nerve,  just  in  front  of  the 
tragus,  is  infiltrated  with  a  few  drops  of  a  2  per  cent,  novocain  solution 
complete  anesthesia  is  secured  (Skillern,  1913).     After  opening,  the 


'    ...  '  I 


Fig.  748. — Examination  of  external  auditory  canal  by  light  reflected  from  a 

head-mirror. 

crater  of  the  furuncle  should  be  touched  with  a  drop  of  tincture  of 
iodin  or  pure  carbolic  acid;  and  a  small  pledget  of  cotton  should  be 
introduced,  and  an  aseptic  dressing  then  bandaged  to  the  auricle. 

Hematoma  Auris  or  Othematoma  usually  is  the  result  of  a  blow. 
It  is  not  uncommon  in  patients  in  insane  asylums,  who  can  give  no 
account  of  its  appearance;  and  on  this  account  it  has  been  thought 

to  have  some  occult  connection  with  un- 
soundness of  mind.  If  it  ever  develops 
spontaneously,  it  probably  is  to  be  attrib- 
uted to  arteriosclerotic  changes.  The 
effused  blood  separates  the  skin  from  the 
cartilage,  usually  over  the  pinna;  and 
unless  proper  treatment  is  instituted  the 
auricle  will  become  conspicuously  deformed 
from  organization  and  cicatrization  of  the 
thrombus.  The  blood  may  be  aspirated 
by  a  hypodermic  needle  in  very  recent 
cases;  but  usually  the  blood  is  semi-clotted, 
and  an  incision  is  necessary.  This  should 
be  made  along  the  helix  (Fig.  749),  and 
after  the  blood  is  evacuated  the  skin  should 
be  reapplied  very  carefully  to  the  underlying  cartilage  and  should  be 
held  against  it  by  accurate  adjustment  of  small  pads  and  a  firm  band- 


Fig.  749. — Proper  incision    to 
evacuate  an  othematoma. 


SURGERY  OF  THE  EAR  677 

age.  Unless  this  coaptation  is  very  firm  and  exact,  re-accumulation 
of  blood  will  occur.    After  a  few  days  massage  should  be  employed. 

Prominence  of  the  Auricle,  either  congenital  or  acquired,  may  be 
remedied  by  suitable  plastic  operation.  In  the  usual  congenital  form 
the  pinna  hangs  down  like  a  hood,  and  the  condition  is  named  "lop- 
ear."  It  may  be  sufficient  to  remove  an  ellipse  of  skin  from  the  pos- 
terior surface  of  the  auricle  and  adjoining  scalp,  and  then  to  suture 
the  ear  against  the  head  and  keep  it  in  place  by  a  firm  bandage.  Some 
such  support  should  be  worn  for  several  weeks.  Usually  it  is  neces- 
sary to  excise  some  of  the  cartilage  of  the  auricle  also. 

Supernumerary  Auricles  are  not  very  rare.  Excision  is  the  proper 
treatment. 

Otitis  Media. — The  middle  ear  is  a  mucous-lined  cavity,  draining 
into  the  pharynx  through  a  long  and  narrow  channel,  the  Eustachian 
tube.  Infection  usually  ascends  from  the  pharynx,  which  often  is 
septic,  especially  if  adenoids  are  present.  Occlusion  of  the  Eustachian 
tube  or  of  either  of  its  orifices  renders  the  middle  ear  a  closed  chamber 
where  microbes  are  prone  to  multiply  and  increase  in  virulence.  The 
middle  ear  in  these  respects  resembles  the  vermiform  appendix.  In 
cases  of  middle-ear  disease  or  its  complications,  the  services  of  an 
otologist  are  desirable;  but  as  these  cannot  always  be  obtained  in 
emergency,  the  general  surgeon  may  be  called  upon  to  treat  the 
acute  stages  of  such  lesions.  Only  emergency  treatment,  therefore, 
is  considered  in  this  work. 

Catarrhal  inflammation  of  the  middle  ear  frequently  develops  after 
an  attack  of  measles,  pneumonia,  scarlatina,  or  other  infectious 
disease.  It  is  accompanied  by  ear-ache,  slight  deafness,  a  sense  of 
fulness  in  the  ear,  slight  feverishness,  and  probably  some  dysphagia. 
Inspection  of  the  drum  membrane,  with  reflected  light,  through  a 
speculum,  shows  it  reddened  and  swollen,  and  sometimes  bulging, 
especially  in  the  posterior  part.  By  moving  the  patient's  head  back 
and  forth  it  may  be  possible  to  see  the  undulation  of  fluid  through  the 
semi-transparent  drum  membrane.  Later  the  membrane  becomes 
opaque. 

In  acute  purulent  inflammation  of  the  middle  ear  the  symptoms 
are  the  same  in  kind  though  usually  more  severe  in  degree.  The 
affection  usually  is  purulent  from  the  first,  and  does  not  follow 
catarrhal  inflammation.  In  children  the  affection  may  run  its  course 
almost  without  pain,  although  pressure  on  the  tragus  usually  is  painful, 
as  the  bony  canal  is  still  incomplete,  and  movements  of  the  auricle  are 
communicated  to  the  middle  ear.  Often  only  a  sudden  rise  of  tempera- 
ture will  show  any  deviation  from  the  normal.  This  is  so  frequently 
the  case  in  children  that  any  sudden  rise  of  temperature  during  con- 
valescence from  the  exanthemas,  influenza,  bronchitis,  etc.,  demands 
examination  of  the  ears.  If  such  examination  is  neglected,  the  first 
thing  to  attract  attention  to  the  ear  may  be  the  discharge  of  pus 
following  spontaneous  perforation  of  the  drum  membrane. 


678  SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 

Treatment. — Simple  "ear-ache,"  which  may  be  due  to  referred 
pain  from  pharyngeal  or  dental  affections,  or  may  be  a  mild  form  of 
catarrhal  otitis  media,  usually  may  be  relieved  by  instillation  into  the 
external  auditory  canal  of  a  few  drops  of  hot  water.  This  is  quite  as 
efficient  as  hot  laudanum  or  other  drug.  It  is  the  heat  rather  than  the 
drug  that  is  effective.  If  there  is  evidence  of  accumulation  of  fluid 
within  the  tympanic  cavity,  especially  if  there  is  any  bulging  of  the 
membrane,  this  should  be  incised  (myringotomy):  after  suitable  cleans- 
ing of  the  canal  by  dilute  hydrogen  peroxide  and  aseptic  syringing, 
the  incision  is  made  in  a  curved  line  around  the  entire  posterior  cir- 
cumference of  the  drum  membrane,  thus  forming  a  flap,  which  allows 
much  more  free  and  prolonged  drainage  than  a  mere  puncture.  The 
point  of  the  knife  should  not  do  more  than  penetrate  the  membrane, 
as  the  tympanic  cavity  may  be  very  shallow.  The  ear  is  drained  by 
a  small  strip  of  gauze  extending  just  as  far  as  the  drum  membrane; 
this  should  be  renewed  as  often  as  it  becomes  soaked  with  discharge — 
several  times  an  hour  if  necessary.  Several  times  daily,  not  oftener 
than  every  two  or  three  hours,  the  canal  should  be  irrigated 
gently  with  a  weak  antiseptic  solution.  Heat  to  the  mastoid  will 
be  grateful,  and  sedatives  may  be  requisite  to  allay  the  pain.  The 
patient  must  be  confined  to  bed  for  several  days.  The  nasopharynx, 
whence  the  infection  usually  has  come,  should  receive  appropriate 
treatment. 

Acute  Mastoiditis. — Invasion  of  the  mastoid  cells,  by  extension 
of  inflammation  from  the  middle  ear  through  the  aditus  and  the 

antrum,  occurs  in  many  cases  of  acute 
purulent  otitis  media.  Prompt  treatment 
of  the  middle-ear  disease  by  myringotomy 
will  permit  recovery  in  many  cases  without 
permanent  damage  to  the  antrum  or  mas- 
toid. If  the  discharge  of  pus  persists  long, 
and  is  profuse,  in  spite  of  proper  conserv- 
ative treatment  of  the  middle  ear,  it  us- 
ually indicates  that  there  is  involvement 
of  the  mastoid  cells.  This  is  a  chronic 
condition,  however,  and  does  not  concern 
us  here.  Not  infrequently,  shortly  before 
symptoms  of  acute  mastoiditis  appear,  an 
ear  which  had  been  "running"  for  months 

Fig.  750.  —  Mastoid  abscess  j  j      1  a       j*     i_ 

(left)    pointing  through   petro-     or   years  suddenly   ceases   to  discharge, 
mastoid  suture.    Age  three  and     The  patient  has  pain  in  and  behind  the 

a  half  years.    (Dr.  Gibbs  s  case.)  7,  P  ,  ■,  .„. 

Episcopal  Hospital.  ear;  there  is  fever,  perhaps  chilliness  or 

an  actual  chill;  headache  and  general 
malaise.  The  mastoid  is  tender,  not  only  at  its  tip,  as  sometimes 
occurs  in  cases  of  simple  otitis  media,  but  especially  over  the  emis- 
sary vein  and  the  antrum;  and  in  some  cases  there  is  evidence  of 
periosteitis.  In  children  pus  often  makes  its  way  outward  along  the 
petro-mastoid  suture,  bulges  beneath  the  periosteum,  and  causes  the 


SURGERY  OF  THE  EAR  679 

auricle  to  stand  away  from  the  head  in  a  very  characteristic  manner 
(Fig.  750).  In  rarer  cases  an  abscess  forms  deep  in  the  neck  beneath 
the  sternomastoid  muscle  (Bezold's  abscess).  In  adults  movement  of 
the  auricle  is  not  painful;  this  is  an  important  differential  sign  from 
furunculosis  of  the  external  auditory  meatus.  But  in  children,  in 
whom  the  bony  canal  is  less  well  developed,  movement  of  the  auricle 
is  communicated  to  the  middle  ear  and  hence  usually  causes  pain. 

Diagnosis. — This  rests  on  the  previous  history  of  the  case,  namely, 
onset  of  ear  trouble  usually  in  convalescence  from  an  acute  infectious 
disease;  on  the  existence,  past  or  present,  of  chronic  otitis  media; 
and  on  physical  examination  of  the  ear,  showing  mastoid  tenderness, 
redness,  and  edema,  perhaps  with  protrusion  of  the  auricle. 

Prognosis. — If  the  infecting  organism  is  the  staphylococcus  or  even 
the  pneumococcus,  recovery  without  operative  treatment  (other 
than  myringotomy)  may  occur  in  a  fair  proportion  of  cases.  Where 
the  streptococcus  or  the  Bacillus  mucosus  capsulatus  is  found,  bone 
destruction  is  apt  to  be  much  greater,  and  very  seldom  can  operation 
be  avoided. 

Treatment. — In  cases  which  develop  soon  or  immediately  after  the 
first  appearance  of  an  otitis  media,  operation  on  the  mastoid  may  be 
delayed  one  or  two  days,  to  ascertain  what  effect  the  myringotomy 
will  have  on  the  mastoid  symptoms.  But  if  the  B.  mucosus  capsu- 
latus is  found  in  the  discharge  from  the  middle  ear  no  delay  in  operating 
should  be  permitted;  operation  should  not  be  postponed  even  until  the 
next  day.  When  the  streptococcus  is  found  delay  never  should  be 
longer  than  one  week,  even  when  clear  signs  of  mastoiditis  are 
lacking.  Prompt  drainage  of  the  infected  bone  is  demanded.  There 
is  great  risk  of  sinus  thrombosis  (p.  621)  or  brain  abscess  (p.  624)  if 
there  is  delay,  especially  in  cases  occurring  as  exacerbations  of  long 
standing  middle-ear  disease  with  inefficient  drainage. 

Operation  for  Acute  Mastoiditis. — An  incision  is  made  from  the  tip 
of  the  mastoid  process  upward,  parallel  with  and  about  5  mm.  post- 
erior to  the  attachment  of  the  auricle,  for  a  distance  of  5  to  8  cm. 
This  incision  passes  directly  to  the  bone,  but  as  in  children  the  bone  is 
very  soft,  great  care  should  be  taken  not  to  cut  too  deeply.  If  the 
posterior  auricular  artery  is  divided,  it  should  be  clamped  and  ligated 
at  once.  The  periosteum  is  then  separated  from  the  bone  throughout 
the  length  of  the  incision,  for  a  space  2  to  3  cm.  in  width,  exposing  the 
posterior  wall  of  the  external  auditory  meatus,  and  the  suprameatal  spine 
ofHenle.  The  sternomastoid  muscle  is  then  detached  from  the  mastoid 
tip,  cutting  it  close  to  the  bone.  If  more  room  is  required  at  any  stage 
of  the  operation  an  incision  is  carried  backward  from  the  center  of  the 
post-auricular  incision,  and  the  two  triangular  flaps  so  formed  are 
elevated  from  the  bone.  The  surgeon  next  identifies  the  triangle  of 
Macewen  (1893),  which  lies  above  and  behind  the  external  auditory 
meatus;  it  is  bounded  in  front  by  the  bony  wall  of  this  canal  and  the 
suprameatal  spine,  above  by  the  posterior  root  of  the  zygoma,  and 
posteriorly  by  a  line  joining  these  two  (Fig.  751).    This  triangle  is  the 


GSO 


SURGERY  OF  THE  FACE,   MOUTH,  AND  NECK 


guide  to  the  situation  of  the  antrum,  over  which  it  lies.  In  children 
the  antrum  lies  at  a  higher  level  than  in  adults,  in  whom  it  is  more 
behind  than  above  the  meatus.    Usually  the  bone  directly  covering  the 


Fig.  751. — Macewen's  triangle,  outlined  on  the  skull;  and  the  suprameatal 
spine  of  Henle. 

antrum  is  perforated  by  minute  venous  channels,  and  the  antrum  may 
be  located  in  this  way.    The  antrum  may  be  opened  first  (Fig.  752),  as 


a         b 


Fig.  752. — Operation  upon  the  mastoid 
antrum.  The  antrum  (a)  has  been  laid 
open  and  gouged  out,  and  the  bridge  of 
bone  (6)  between  it  and  the  external  audi- 
tory meatus  is  seen.  (Cheyne  and  Burg- 
hard.) 


Fig.  753. — Operation  upon  the  mas- 
toid antrum.  A  bent  probe  has  been 
introduced  from  the  antrum  to  the 
middle  ear.     (Cheyne  and  Burghard.) 


advised  by  Mace  wen;  or  the  surgeon  may  first  remove  the  cortex  over- 
lying the  mastoid  cells,  from  the  tip  of  the  mastoid  up  to  the  antrum.  If 
a  dental  engine  is  available,  a  rotary  burr  is  a  very  satisfactory  instru- 


SURGERY  OF  THE  EAR  681 

ment.  Usually,  however,  a  gouge  and  mallet  are  used  to  remove  the 
cortex,  and  then  the  pneumatic  cells  are  excavated  by  a  bone  curette 
or  fine  gouge  forceps.  In  young  children  a  strong  curette  will  remove 
the  cortex  also.  The  instruments  should  be  made  to  cut  from  within 
outward,  unless  the  parts  are  fully  exposed.  The  entire  mastoid, 
including  its  tip,  should  be  removed;  and  in  most  cases  all  the  pneu- 
matic cells  which  are  accessible,  wherever  situated,  should  be  removed, 
including  any  in  the  posterior  zygomatic  root.  As  the  pneumatic 
cells  may  extend  along  the  petrous  portion  of  the  temporal  bone  even 
to  its  apex,  it  manifestly  is  impossible  to  remove  all  in  every  case, 
and  in  cases  where  the  patient  is  extremely  septic  it  undoubtedly  is 
better  merely  to  secure  free  drainage,  and  to  leave  the  completion  of 
a  radical  operation  for  another  occasion.  But  in  every  case,  without 
exception,  it  is  necessary  to  open  the  antrum,  and  thus  accomplish 
the  purpose  of  the  operation,  the  securing  of  free  drainage  of  this  region 
of  the  middle  ear  through  the  mastoid.  As  the  bone  is  being  removed 
it  should  be  repeatedly  examined  by  the  probe;  the  antrum  is  recog- 
nized by  the  probe  passing  first  upward,  then  forward  and  inward 
through  the  aditus  into  the  middle  ear  (Fig.  753) .  A  probe  introduced 
into  the  middle  ear  through  the  perforated  tympanic  membrane  may 
be  an  aid  in  locating  the  antrum. 

The  structures  in  most  danger  of  injury  are  the  sigmoid  sinus, 
the  facial  nerve,  and  the  horizontal  semicircular  canal.  If  a  gouge  is 
used,  cutting  from  without  inward,  it  should  be  bevelled  on  its  con- 
vex surface,  and  should  be  applied  very  obliquely  to  the  surface 
of  the  skull,  so  that  if  the  lateral  sinus  (Fig.  690)  is  exposed  it  will  be 
pushed  ahead  of  the  gouge  and  not  wounded.  Usually  the  inner 
(vitreous)  layer  of  the  mastoid  process,  which  separates  the  sinus  from 
the  pneumatic  cells,  may  be  recognized  when  the  latter  have  been 
cleared  away.  If  there  is  reason  to  suspect  sinus  thrombosis,  this 
bone  must  be  removed  also,  and  the  sinus  treated  as  recommended  at 
page  622.  The  facial  nerve  is  in  most  danger  as  it  passes  outward  and 
slightly  backward  beneath  the  floor  of  the  aditus  ad  antrum.  The 
horizontal  semicircular  canal  projects  into  the  median  wall  of  the  aditus 
ad  antrum.  The  curette  should  not  be  used  in  either  of  these  situations. 
The  roof  of  the  antrum  and  the  aditus  is  very  thin,  and  the  middle 
cranial  fossa  lies  directly  above  it;  but  this  will  not  be  opened  if  no  bone 
is  removed  above  the  line  of  the  temporal  ridge  (continuation  of  the 
posterior  root  of  the  zygoma).  The  condition  of  the  bone  forming 
the  tegmen  antri  should  be  ascertained  by  very  gentle  probing.  If 
it  is  carious  or  perforated  it  should  be  removed  gently  with  curette 
or  gouge  forceps,  since  there  may  be  an  extradural  abscess  above 
it  requiring  drainage.  The  treatment  of  intracranial  abscess  has 
been  considered  at  page  625. 

When  the  operation  is  concluded  the  cavity  is  lightly  tamponed 
with  iodoform  gauze,  and  the  skin  incision  closed  except  at  the  lower 
angle.    An  aseptic  dressing  is  applied,  and  the  head  bandaged.    The 


682 


SURGERY  OF  THE  FACE,   MOUTH,   AND  NECK 


after-treatment  requires  great  care.  The  patient  is  confined  to  bed 
for  several  days;  and  the  wound  is  dressed  on  the  third  day,  and  the 
gauze  packing  renewed.  Not  until  firm  granulations  have  formed 
should  syringing  be  employed,  but  the  sinus  left  by  the  operation  and 

the  external  auditory  meatus  may  be  gently  cleansed  with  pledgets 
of  absorbent  COttOD  moistened  with  dilute  hydrogen  peroxide.  The 
subsequent  care  is  that  for  any  granulating  surface.  In  the  most 
favorable  cases  healing  is  complete  in  from  four  to  six  weeks. 

SURGERY  OF  THE  LIPS  AND  PALATE. 

Hare-lip  and  Cleft   Palate. — These,  which   are  conveniently  con- 
sidered together,  are  the  most  frequent  congenital  deformities  of  the 

face.  They  are  best  understood  by 
reference  to  the  accompanying  dia- 
gram (Fig.  754),  which  represents  an 
embryo  of  three  weeks.  The  fronto- 
nasal process  (a)  is  descending  between 
the  maxillary  processes  (b  b).  The 
eyes  are  represented  by  c  C,  and  the 
mandibular  processes  by  </  d.  Failure 
of  the  embryonal  maxillary  processes 
to  coalesce  in  the  median  line  leaves 
a  fissure  of  varying  extent  in  the  upper 
lip  and  palate. 

7/  the  fissure  is  single,  it  does  not 

occupy  the  median  line  but  corresponds 

to  the  line  of  junction   between  the 

intermaxillary  bone   (fronto-nasal  process)  and  the  superior  maxilla. 

But  a  cleft  of  the  soft  palate,  and  one  of  the  back  part  of  the  hard 

palate  is  in  the  median  line,    as  the  frontal  process  (intermaxillary 


Fig.  7"i4. — The  head  of  an  em- 
bryo of  three  weeks.      (See  text.) 


Fig,  755. — Double  hare-lip  ami 

cleft  palate.  Age  two  days. 
Note  the  projecting  intermaxil- 
lary hone.     On hopiedic  Hospital. 


Fig.  750. — Hanging  head  position,  for  operations 
on  the  palate. 


bone)  does  not  extend  backward  so  far.  In  a  complete  double  cleft 
of  the  palate,  therefore,  the  fissure  is  Y-shaped,  double  in  front,  and 
single  behind. 


SURGERY  OF   THE  LIPS  AND   PALATE 


If  the  fissure  is  double,  the  intermaxillary  bone  usually  projects  in 
front  of  the  lip  (Fig.  755),  and  the  fissures  may  involve  both  palate  and 
lip,  or  either  one  to  the  exclusion  of  the  other.  As  a  general  rule  it  may 
be  said  that  cleft  palate  without  hare-lip  is  very  rare,  while  hare-lip 
without  accompanying  deformity  of  the  palate  is  fairly  common. 

The  proper  age  for  operation  always  has  been  a  matter  of  discussion. 
Infants  with  cleft  palate  and  hare-lip  usually  are  stronger  soon  after 
birth  than  subsequently,  owing  to  the  difficulty  of  suckling  them. 
A-  this  difficulty  comes  rather  from  the  lip  than  palate  deformity, 
repair  of  the  former  should  be  done  at  once  if  possible,  when  the  palate 
i-  cleft  also.    Lane  merely  incises  along  the  junction  of  the   -kin  with 


Figs.  7o7  and  758. — Owen's  method  for  complete  single  hare-lip. 

the  vermilion  border,  separates  the  mucosa  and  -kin  slightly  by  dis- 
section, and  sutures  each  separately,  the  mucous  sutures  being  intro- 
duced from  and  tied  on  the  mucous  surface,  and  the  skin  sutures  on  the 
cutaneou-  surface.  The  natural  tension  on  the  -oft  parts  then  may 
cause  considerable  reduction  in  the  width  of  the  palatal  cleft  during 
the  first  year  of  life.  In  such  young  patients  operation  may  be  done 
without  an  anesthetic  if  absolutely  necessary;  they  have  no  appre- 
hension of  pain  or  suffering  to  come,  nor  any  memory  of  it  after  it  has 
pa  -t.  But  in  most  ca-e>  there  i-  no  contra- 
indication to  the  use  of  ether  or  chloro- 
form. Ether  is  preferable  in  older  chil- 
dren and  in  adults.  It  is  administered 
in  the  "hanging  head"  position  CE. 
Rose,  1874j,  and  the  surgeon  sits  at 
the  patient's  head  (Tig.  756; .  The  use 
of  a  tube  for  intrapharyngeal  anestheti- 
zation is  a  great  convenience  (p.  156) . 

Hare-lip. — Single  hare-lip  varies  from 
a  mere  notch  to  a  fissure  extending  into 
the  nostril,  and  perhaps  continuous  with 
a  unilateral  cleft  of  the  palate.  The  prin- 
ciple of  the  operation  consists  in  freshen- 
ing the  edges  of  the  fissure  and  suturing  them  together.  If  operation 
has  been  postponed  until  the  age  of  one  or  two  years,  a  formal  plastic 


Fig.  7-"/j. — Hare-lip  pins  in  use 
with  twisted  suture;  points  of  pins 
cut  off  and  wrapped   in   adhesive 

plaster. 


684  SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 

operation  is  preferable  to  Lane's  method  already  described.  The  lip  is 
first  freely  separated  from  the  upper  jaw,  by  dividing  the  frenum  or 
other  adhesions.  Bleeding  should  be  controlled  promptly  by  mos- 
quito hemostats.  If  there  is  a  mere  notch  in  the  lip  it  is  sufficient 
to  employ  Nelaton's  operation,  which  consists  in  incising  the  lip  in 
the  transverse  direction  above  the  notch,  and  in  suturing  this  incision 
in  the  longitudinal  axis  of  the  body,  thus  lengthening  the  lip  at  the 
expense  of  its  width.  Usually,  however,  it  is  better  to  pare  both  edges 
of  the  fissure  in  a  line  slightly  concave  toward  the  median  line.  The 
knife  is  entered  at  the  apex  of  the  fissure  for  denuding  each  margin; 
and  care  is  taken  that  these  incisions  unite  above  the  apex  of  the  fissure 
and  that  enough  of  each  flap  is  left  at  the  free  border  of  the  lip  to  ensure 
a  'projection  on  the  vermilion  border  when  the  edges  are  united;  if  the 
vermilion  border  is  sutured  flush,  the  contraction  of  the  cicatrix  soon 
will  cause  a  depression.  Interrupted  sutures  of  fine  silkworm  gut  or 
horsehair  are  used.  They  are  introduced  from  the  cutaneous  surface 
down  to  but  not  through  the  mucous  membrane.  Or  hare-lip  pins  and 
a  twisted  suture  may  be  used  for  the  main  support,  with  superficial 
interrupted  sutures  to  secure  accurate  coaptation  (Fig.  759).  To 
improve  the  nostril,  a  wire  suture  shotted  at  both  ends  may  be  passed 
as  indicated  in  Figs.  760  and  761. 


Figs.  760  and  761. — Method  of  improving  the  shape  of  the  nostril.      (Stone.) 

Double  Hare-lip. — The  operation  here  is  the  same  as  in  cases  of 
single  hare-lip,  the  margins  of  each  fissure  being  freshened  and  sutured 
separately;  but  often  it  is  well  to  bring  a  small  flap  from  the  larger  side 
across  beneath  the  intermaxillary  bone,  to  form  the  prolabium;  and 
if  there  is  sufficient  tissue  a  second  still  smaller  flap  from  the  other 
side  may  be  introduced  between  this  flap  and  the  intermaxillary  bone 
If  the  intermaxillary  bone  protrudes  and  cannot  be  pushed  back  into 
place  even  by  division  of  its  attachment  to  the  septum,  it  may  be 
excised;  but  as  it  bears  the  central  incisor  teeth  this  should  not  be 
done  recklessly. 

After  the  operation  the  parts  are  painted  with  Whitehead's  varnish,1 
and  a  long  strip  of  adhesive  plaster  is  applied  from  one  ear  to  the  other 

*I$ — Extr.  fl.  benzoin 12.5  c.c. 

Iodoform 12.5  gm. 

Ether 75.0  c.c. 


SURGERY  OF  THE  LIPS  AND  PALATE 


685 


across  the  upper  lip.  The  baby  should  be  put  to  the  breast  or  fed 
from  a  bottle  as  soon  as  convenient,  as  the  motions  involved  in  sucking 
tend  to  lessen  tension  on  the  sutures.  Minute  doses  of  paregoric  may 
be  required  to  check  crying.  Every  alternate  stitch  may  be  removed 
about  the  fourth  or  sixth  day,  and  the  remainder  from  the  eighth  to 
the  tenth  day. 

Cleft  Palate. — If  the  operation  is  done  in  early  infancy  the  max- 
illary bones  are  cartilaginous,  and  may  be  brought  into  apposition 
by  moderate  pressure  (Brophy  1900) ;  but  it  is  probable  that  the  maxillae 
are  not  abnormally  distant  from  each  other,  and  that  the  defect  is  lack 
of  tissue  in  the  median  line.  Nevertheless  Brophy's  operation  permits 
suture  of  the  vivified  margins  of  the  cleft  without  tension,  and  restora- 
tion of  normal  relations  of  the  parts  concerned  in  phonation  before  the 
child  begins  to  talk.  Lane  (1897)  also  operates  at  as  early  an  age  as 
possible.  If  the  operation  is  not  done  until  after  the  age  of  two  years, 
and  particularly  in  older  children  and  adults,  a  much  more  difficult 
and  tedious  method  will  have  to  be  employed,  and  the  patient  will  have 
acquired  improper  habits  of  speaking  which  he  never  will  be  able  com- 
pletely to  abandon.  When  the  operation  for  cleft  palate  is  confined  to 
the  soft  palate,  it  is  known  as  staphylorrhaphy;  if  it  involves  the  hard 
palate  it  is  called  uranoplasty.  Before  operation  is  undertaken  it  is 
important  that  the  patient  be  free  of  coryza,  pharyngitis,  or  other 
inflammatory  conditions  of  the  upper  respiratory  tract.  The  best  age 
for  operation,  in  the  opinion  of  the  majority  of  surgeons,  is  during  the 
second  year. 

Early  operation. — This  consists  essentially  in  passing  sutures  of 
heavy  wire  across  the  cleft  (above  the  horizontal  process  of  the  palate 
bone)  from  the  buccal  surface  of  one 
maxilla  to  that  of  the  other  (Fig.  762). 
These  sutures  are  then  twisted  tightly 
together  over  perforated  lead  plates;  and 
when  the  maxillae  are  thus  approximated 
the  margins  of  the  palatal  cleft  (pre- 
viously denuded)  are  sutured  together 
with  interrupted  sutures  of  silkworm  gut. 
The  wire  sutures  are  removed  after  four 
to  six  weeks.  Though  some  slight  pres- 
sure ulceration  may  occur  beneath  the 
lead  plates  no  permanent  harm  is 
done. 

Late  Operation. — Here  the  maxilla;  cannot  be  approximated,  and  it 
is  necessary  to  close  the  cleft  solely  by  means  of  the  soft  parts. 

Fergusson's  Operation  (1844).— The  margins  of  the  cleft  are  freshened 
first.  If  they  cannot  be  made  to  meet,  an  incision  is  made  through 
the  mucous  membrane  and  periosteum  of  the  hard  palate  close  to  the 
alveolar  process;  this  is  not  carried  so  far  posteriorly  as  to  divide  the 
trunk  of  the  descending  palatine   artery  as    it  emerges   from  the 


Fig.  762. — Wire  sutures  passed 
for  uranoplasty  in  infancy. 


6SG 


SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 


posterior  palatine  foramen,  and  it  is  placed  so  close  to  the   alveolus 
as    to   leave    most  of    the  branches  of  this  artery  on  the  median 

side  of  the  incision.  Bleed- 
ing, which  usually  is  very 
free,  is  controlled  by  pack- 
ing the  incision  with  gauze 
while  a  similar  incision  is 
made  in  the  palate  of  the 
other  side.  The  mucous 
membrane  and  periosteum 
are  now  separated  from  the 
hard  palate  by  suitable  peri- 
osteal elevators  from  these 
lateral  incisions  to  the 
median  cleft  (Fig.  763). 
Even  when  these  flaps 
have  been  thus  freed,  it 
may  be  impossible  to  make  the  edges  of  the  cleft  meet  in  the 
median  line  without  undue  tension.  The  higher  the  arch  of  the  palate 
the  easier  will  it  be  to  make  the  flaps  meet,  when  thus  separated 
from  the  palate  above.     To  overcome  the  remaining  tension  it  may  be 


Fig.  763. 


—Separating  the  muco-periosteal  flap  in 
the  operation  for  cleft  palate. 


Fig.  764. — Cutting  the  aponeurosis  of  the 
velum  at  its  insertion  in  the  hard  palate. 


Fig.  765. — Introduction  of  sutures 
in  the  operation  for  cleft  palate. 


necessary  to  divide  the  aponeurosis  of  the  soft  palate  at  its  attachment 
to  the  hard  palate.  This  is  accomplished  by  use  of  scissors  bent  on 
the  flat  almost  to  a  right  angle;  one  blade  is  inserted  between  the 
detached  mucoperiosteum  and  the  under  surface  of  the  back  of  the 
hard  palate,  and  the  other  along  the  nasal  surface  of  the  soft  palate 
(Fig.  764) .  The  freshened  edges  of  the  cleft  are  finally  united  by  inter- 
rupted sutures  of  silkworm  gut,  passed  by  means  of  small  curved 
needles,  as  indicated  in  Fig.  765.  The  sutures  may  be  secured  by 
clamping  perforated  shot  over  their  ends.  The  wound  is  then  covered 
by  Whitehead's  paint. 


SURGERY  OF   THE  LIPS  AND  PALATE 


687 


Lane's  Operation. — In  this,  a  flap  of  mucoperiosteum  is  detached, 
inverted,  and  fixed  by  sutures  under  the  opposite  edge  of  the  cleft 
(Figs.  766  and  767).  The  raw  surfaces  exposed  are  left  to  heal  by 
granulation.  If  the  operation  is  done  before  eruption  of  the  teeth  a 
wider  flap  can  be  secured. 


Figs.  766  and  767. — Lane's  operation  for  cleft  palate.  The  flap  a  be  is  raised  along 
the  dotted  line,  is  inverted  along  a  c  as  el  hinge,  and  its  free  edge  is  sutured  to  the  fresh- 
ened margin  def. 


In  the  after-treatment  the  patient,  especially  if  an  infant,  must  be 
kept  with  the  head  low,  and  so  placed  that  vomited  matters,  mucus, 
blood,  etc.,  find  a  ready  exit.  If  no  marked  opposition  is  encountered 
it  is  well  to  spray  the  mouth  and  nasal  cavities  with  some  weak  anti- 
septic solution  every  three  or  four  hours.  Speaking  should  not  be 
permitted  for  a  week  at  the  least.  Liquid  diet  (meat  juices  or  broth 
being  preferable  to  milk)  should  be  employed  until  after  removal  of 
the  sutures,  when  soft  diet  may  be  allowed.  The  sutures  should  not  be 
removed  for  ten  days  unless  they  begin  to  cut  out  sooner.  If  the  opera- 
tion is  not  a  success,  from  partial  or  complete  sloughing,  another 
attempt  should  not  be  made  for  at  least  a  month,  so  as  to  allow  the 
inflammatory  swelling  to  subside. 

After  convalescence  voice  and  speech  training  should  be  systemati- 
cally instituted.  The  usual  defect  in  speech  comes  from  the  continued 
habit  of  speaking  through  the  nose.  Such  exercises,  therefore, 
are  to  be  enjoined  as  cause  the  child  to  speak  through  the  mouth, 
raising  the  palate  high  against  the  pharynx  and  depressing  the 
larynx. 

Acquired  Perforations  of  the  Palate,  the  result  of  syphilis,  of  trauma, 
or  of  sloughing  following  infection,  are  very  difficult  to  close  by  opera- 
tion, and  none  should  be  attempted  until  the  parts  are  in  healthy 
condition.  Usually  a  flap  of  mucous  membrane  must  be  inverted 
from  one  or  both  sides  of  the  perforation.  These  are  sutured  together 
and  the  denuded  area  left  to  heal  by  granulation.    In  cases  not  admit- 


ess 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


Fig.  768. — Macrocheilia  in  a 
boy  of  seven  and  a  half  years; 
not  congenital;  followed  cellu- 
litis from  injury  at  eighteen 
months  of  age.  Orthopedic 
Hospital. 


ting  of  operative  relief  some  form  of  obturator  should  be  worn  in  the 
form  of  a  plate  attached  to  the  teeth.  The  obturator  never  should 
be  introduced  into  the  perforation  itself,  as  this  would  surely  cause 
it  to  grow  larger  by  atrophy  from  pressure. 

Macrocheilia. — Abnormal  size  of  the  lips,  usually  the  lower,  may 
be  due  to  a  congenital  condition  of  lymphangiectasis.  This  often 
does  not  cause  marked  deformity  until 
the  age  of  puberty.  Or  the  condition 
may  be  acquired  as  the  result  of  hyper- 
trophy following  recurrent  attacks  of 
cellulitis  (Fig.  768).  It  frequently  is  ac- 
companied by  an  adenomatous  condition 
of  the  mucous  glands  of  the  lip  which 
may  be  palpable  as  shot-like  nodules 
beneath  the  mucous  membrane.  The 
treatment,  if  any  is  demanded,  consists 
in  excision  of  a  wedge-shaped  section 
all  across  the  lip,  with  suture  of  the 
mucous  to  the  cutaneous  border. 

Cysts. — Cysts  of  the  labial  mucous 
glands  form  small,  rounded,  submucous 
tumors.  They  may  follow  biting  the 
lip.    If  punctured  the  cysts  are  apt  to 

refill,  so  it  is  better  to  excise  the  anterior  wall  and  cauterize  the 
lining  membrane. 

Carbuncle. — Carbuncle,  when  it  affects  the  upper  lip,  is  an  unusu- 
ally serious  form  of  the  disease,  from  the  danger  of  intracranial  com- 
plications by  thrombosis  and  embolism  through  the  facial  and  angular 
veins.  Bullock  (1912)  collected  notes  of  27  cases,  with  six  deaths,  a 
mortality  of  22  per  cent.  He  advocates,  and  practised  with  success 
in  one  case,  early  ligation  of  the  facial  veins  about  half  an  inch  below 
the  inner  canthus  of  each  eye.  Early  and  free  incision  of  the  carbuncle 
is  important,  regardless  of  apparent  deformity,  as  this  may  be  remedied 
later  by  skin-grafting  or  plastic  operation. 

Epithelioma. — Epithelioma  of  the  lip  is  a  frequent  condition,  and 
for  successful  treatment  requires  early  recognition.  Frequently  it 
follows  chronic  local  irritation,  notably  the  heat  from  a  short-stemmed 
clay  pipe;  the  explanation  is  that  the  moistened  epithelium  sticks  to 
the  absorbent  clay  and  is  peeled  off  the  lip  as  the  pipe  is  removed. 
An  exfoliation  results,  with  a  tendency  to  keratosis.  Less  than  9  per 
cent,  of  cases  of  epithelioma  of  the  lip  occur  in  women;  in  men  there 
is  only  one  case  in  the  upper  lip  to  45  in  the  lower,  while  in  women 
there  is  one  in  the  upper  to  every  7  in  the  lower  lip  (Butlin).  The 
lesion  usually  begins  to  one  side  of  the  median  line  on  the  vermilion 
border  of  the  lip  (muco-cutaneous  junction),  and  almost  without 
exception  is  of  the  more  malignant  deep-seated  type  of  epithelioma. 
An  epithelioma  beginning  on  the  cutaneous  surface  of  the  lip  often  is 
of  the  less  malignant  superficial  type  (rodent  ulcer). 


SURGERY  OF  THE  LIPS  689 

The  deep-seated  epithelioma  growing  on  the  vermilion  border  of 
the  lip  may  arise  in  a  seborrheic  patch,  or  as  a  primary  papilloma. 
The  former  is  much  commoner.  The  lip  is  supplied  by  a  row  of  seba- 
ceous glands  which  often  are  visible  in  lips  that  appear  to  be  normal, 
"  as  a  slightly  shaded  or  as  a  glittering  band  that  stretches  like  a  bow 
across  the  front  of  the  lips  between  one  corner  of  the  mouth  and  the 
other,"  about  half  a  centimeter  above  the  cutaneous  border  (Mont- 
gomery). Somewhere  on  this  line,  crusts  tend  to  form,  and  a  typical 
seborrheic  patch  develops.  Early  invasion  of  the  regional  lymphatics 
occurs;  but  they  are  microscopically  infected  long  before  they  become 
palpable.  They  should  be  searched  for  carefully,  the  finger  of  one 
hand  being  placed  in  the  floor  of  the  mouth,  and  the  fingers  of  the 
other  hand  beneath  the  chin.  The  submental  nodes  are  those  first 
affected,  then  those  around  the  submaxillary  salivary  glands  (both 
sides),  and  finally  the  deep  cervical  lymph  nodes  along  the  great 
vessels.  The  nodes  at  first  are  indurated,  and  usually  painless;  but 
rarely  are  they  distinctly  palpable  until  the  labial  ulcer  has  existed 
for  many  months.  As  already  remarked,  long  before  they  are  palpable, 
probably  within  three  or  four  months  of  the  appearance  of  the  lip 
lesion,  microscopical  examination  of  the  submental  nodes  will  show 
the  presence  of  carcinoma  cells. 

As  time  goes  on,  the  labial  ulcer  becomes  a  foul,  f ungating,  stinking 
crater;  the  cervical  lymphatics  form  conspicuous  tumors;  they  adhere 
to  the  skin  and  form  secondary  ulcers  of  the  same  foul  character  as 
in  the  lip.  The  patient  cannot  eat;  the  stench  renders  him  loathsome 
to  himself  and  every  one  near  him;  strength  gradually  fails;  hemor- 
rhages from  the  growth  may  occur;  the  trachea  or  esophagus  may  be 
compressed;  and  he  dies  a  miserable  and  painful  death,  but  not  as 
rapidly  as  he  could  wish. 

Diagnosis. — The  diagnosis  seldom  offers  much  difficulty.  Epithe- 
lioma occurs  very  rarely  in  patients  under  middle  age;  it  is  predis- 
posed to  by  exposure  to  weather,  by  chronic  local  irritation  of  any 
kind;  the  area  affected  is  covered  with  adherent  crusts,  which  reveal 
a  small  bleeding  ulcer  when  removed;  from  the  surface  of  the  ulcer 
it  may  be  possible  to  squeeze  out  the  epithelial  pearls  and  columns 
of  cancer  cells  lining  the  sebaceous  ducts;  the  crusts  soon  form  again; 
and  the  regional  lymph  nodes  are  not  palpably  enlarged  until  the  lesion 
has  existed  for  a  number  of  months.  A  chancre  of  the  lip  (Eig.  1008)  is 
of  much  more  acute  development;  may  occur  at  any  age;  is  frequent  on 
the  upper  lip;  presents  parchment-like  induration;  does  not  tend  to  scab 
but  has  a  macerated  or  sloughy  surface  which  is  very  little  inclined  to 
bleed;  a  history  of  contagion  usually  can  be  elicited;  lymphatic  enlarge- 
ments occurs  within  a  few  weeks,  the  nodes  being  soft  and  juicy  on 
palpation;  microscopic  examination  of  smears  from  the  lesion  usually 
will  reveal  the  presence  of  the  Treponema  pallidum;  in  due  time  skin 
lesions  make  their  appearance;  and  antisyphilitic  treatment  is  curative. 
A  gumma  of  the  lips  is  quite  rare;  it  is  painless;  there  is  no  lymphatic 

44 


GOO  SURGERY  OF  THE  FACE,   MOUTH,  AND  NECK 

enlargemenl ;  the  history  or  evidence  of  other  syphilitic  lesions  usually 
c;in  be  obtained;  and  antisyphilitic  treatment  is  rapidly  effective. 

Prognosis. — The  expectation  of  life  in  cases  in  which  no  operation 
is  done  is  from  three  to  five  years  from  the  commencement  of  the 
disease,  and  about  eighteen  months  from  the  time  of  diffuse  lymphatic 
involvement.  If  radical  operation  is  done  before  the  lymphatics  are 
perceptibly  enlarged,  from  50  to  60  per  cent,  of  patients  will  be  free 
from  recurrence  three  years  later;  of  those  in  whom  recurrence  takes 
place  a  small  proportion  can  be  permanently  cured  by  a  second  opera- 
tion, and  the  others  will  have  an  expectation  of  life  dating  from  the 
period  of  recurrence.  Recurrence  is  much  more  apt  to  develop  in  the 
lymphatics  than  in  the  lip;  and  a  growth  which  develops  in  the  lip  may 
not  be  a  recurrence,  strictly  speaking,  but  a  development  of  a  new 
epithelioma  from  a  seborrheic  patch  in  the  neighboring  skin  used  in 
forming  the  new  lip  at  the  first  operation. 

Treatment. — A  lesion  on  the  lower  lip  which  is  merely  suspected 
of  being  carcinomatous  should  be  excised,  with  a  margin  of  at  least 
0.5  cm.  on  all  sides,  and  subjected  to  microscopical  examination. 
If  there  is  no  evidence  of  malignancy  this  operation  may  be  regarded 
as  sufficient.  If  the  patient  refuses  to  have  the  suspected  patch 
excised,  treatment  as  for  keratosis  senilis  (page  669)  may  be  in- 
stituted; but  the  surgeon  should  not  forget  that  he  is  dealing  in  the 
lower  lip  with  a  very  different  form  of  epithelioma  from  the  rodent 
ulcer  where  such  treatment  is  in  a  few  cases  successful.  There  need 
be  no  anticipation  of  success  if  the  growth  on  the  lower  lip  is  really 
an  epithelioma.  If  such  a  lesion  is  either  clinically  or  microscopically 
malignant,  it  is  necessary  to  remove  the  adjacent  lymph  nodes  also. 
The  growth  on  the  lower  lip  should  then  be  excised  with  a  margin  of 
at  least  1  cm.  each  side,  by  incisions  at  right  angles  to  the  line  of  the 
lip,  not  by  a  V-shaped  incision. 

The  operation  introduced  by  Grant,  of  Denver  (1899),  usually  is 
employed  (Figs,  770  and  771).  After  excision  of  the  lesion,  usually 
including  most  of  the  lower  lip,  in  form  of  a  rectangle,  incisions  are 
carried  downward  and  outward  from  the  lower  angles  of  this  rectangle, 
so  as  to  expose  the  submaxillary  region  on  each  side.  These  regions 
are  then  cleared  of  lymph  nodes,  ligating  the  facial  vessels  if  necessary. 
Finally  the  submental  lymph  nodes  are  removed  through  a  separate 
median  incision.  By  drawing  together  in  the  median  line  the  flaps 
outlined  by  the  two  lateral  incisions,  the  lower  lip  is  well  restored 
without  further  plastic  procedure.  The  other  chief  merit  claimed 
for  this  operation  is  that  it  leaves  the  point  of  the  chin  untouched, 
and  that  this  serves  as  a  firm  basis  of  support  for  the  new  lower  lip. 
But  it  will  be  noted  that  this  method  of  operation  does  not  remove 
the  labial  growth  in  one  mass  with  its  related  lymphatics,  but  extir- 
pates the  diseased  tissue  in  three  or  four  separate  sections.  Moreover, 
the  cavity  of  the  mouth  is  opened  as  the  first  step  in  the  operation, 
exposing  the  entire  wound  to  contamination  during  the  tedious  dis- 
section of  the  submaxillary  and  submental  regions. 


SURGERY  OF  THE  LIPS 


691 


For  these  reasons  I  think  it  is  better  to  commence  the  operation 
by  the  removal  of  the  submental  and  submaxillary  lymphatics  (J. 
Clark  Stewart,  1910).  These  regions  are  well  exposed  by  making  a  long 
curved  incision  which  corresponds  to  those  incisions  of  Grant's  operation 


Fig.  769. — Grant's  operation  for  epithe- 
lioma of  the  lower  lip. 


Fig.  770. — Grant's  operation 
completed. 


which  are  represented  by  solid  lines  in  Fig.  769.  The  skin  over  the  point 
of  the  chin  may  be  left  attached  by  carrying  this  first  incision  a  little 
lower  than  indicated.  The  flap  thus  outlined  is  dissected  downward, 
including  with  the  skin  only  the  platysma,  and  leaving  the  fatty  and 
lymphatic  tissues  in  situ.    When  the  submental  and  both  submaxillary 


Fig.  771. — Epithelioma  of  lower  lip.  Above  is  seen  the  area  of  lip  excised,  and 
below  the  mass  of  tissue  containing  lymph  nodes  excised  in  one  piece  from  submental 
and  both  submaxillary  regions.     Episcopal  Hospital. 

regions  have  been  exposed  in  this  way,  they  are  cleared  of  lymphatics 
and  fat  by  dissection  from  below  upward ;  and  the  diseased  structures 
are  removed.  Incisions  are  then  made  upward  into  the  mouth  on  each 
side  of  the  labial  growth,  and  the  lower  lip  is  excised  (Fig.  771).    The 


692  SURGERY  OF   THE  FACE,  MOUTH,  AND  NECK 

submental  flap  is  then  sutured  to  the  point  of  the  chin,  and  the  Lateral 

flaps  are  united  in  the  median  line  as  in  Grant's  operation  (Fig.  770). 
It  is  well  to  drain  both  submaxillary  regions  from  the  outer  angles  of 
the  lateral  incisions  for  several  days.  Where  the  dissection  has  been 
very  extensive  it  is  better  to  carry  a  tube  from  the  submental  region 
in  the  median  line  through  the  floor  of  the  mouth,  draining  the  buccal 
secretions  directly  into  the  dressings,  and  thus  lessening  the  chance 
of  infecting  the  suture  lines.  The  portions  of  the  skin  incisions  not 
drained  should  be  painted  with  Whitehead's  varnish  (p.  G84). 

SURGERY  OF  THE  TONGUE. 

Tongue-tie.  —  It  happens  occasionally,  though  not  so  often  as 
mothers  believe,  that  an  infant  is  born  with  congenital  shortness  of 
the  fraenum  Ungues.  The  tongue  then  is  held  against  the  floor  of  the 
mouth,  cannot  be  protruded  beyond  the  alveolar  margin,  and  may 
occasion  slight  difficulty  in  suckling.  The  condition  is  easily  remedied 
by  snipping  with  scissors  the  tense  band  close  to  the  floor  of  the 
mouth  (to  avoid  the  ranine  vessels  which  run  beneath  the  tongue), 
and  then  stripping  the  tongue  upward  by  the  fingers  as  far  as  needed. 
The  bifid  blade  at  one  extremity  of  the  grooved  director  (Fig.  789)  is 
a  convenient  retractor  to  hold  the  tongue  away  from  the  floor  of  the 
mouth,  while  the  frenum  is  being  divided.  If  the  separation  of  the 
tongue  from  the  floor  of  the  mouth  is  carried  too  far,  there  is  danger 
of  the  baby  being  suffocated  by  "swallowing"  the  tongue. 

Macroglossia. — Abnormal  enlargement  of  the  tongue,  when  not 
dependent  upon  constitutional  causes,  such  as  cretinism,  may  be 
congenital  or  acquired,  as  in  the  pathologically  analogous  condition 
of  macrocheilia  (p.  688),  and  from  similar  causes.  In  congenital 
cases  the  patients  usually  are  mentally  deficient.  The  protruding 
tongue  becomes  inflamed  and  dry  from  exposure  to  the  air,  resulting 
in  stomatitis,  with  collection  of  sordes,  fetor  of  the  breath,  etc.  In 
time  the  incisor  teeth  of  both  jaws  are  pressed  forward  and  the  alveolar 
processes  are  distorted;  but  this  deformity  rarely  becomes  permanent 
before  the  tenth  year. 

Treatment. — Treatment  consists  in  partial  excision,  usually  of  a 
wedged-shaped  portion  of  the  tip  of  the  tongue,  with  suture  of  the 
remaining  lateral  flaps  in  the  mid-line.  Or,  as  the  thickness  of  the 
tongue  usually  is  more  obnoxious  than  its  breadth,  a  transverse  resec- 
tion may  be  done,  making  superior  and  inferior  flaps.  Preliminary 
ligation  of  the  lingual  arteries  may  be  advisable  if  the  tongue  is  very 
large,  and  Armstrong  recommends  the  use  of  silver  wire  instead  of 
silkworm  gut  for  suturing  the  tongue.  The  best  time  for  operation 
is  from  the  third  to  the  sixth  year. 

Ranula. — Ranula  is  a  cystic  tumor  between  the  tongue  and  the  floor 
of  the  mouth.  It  is  a  clinical  term,  possibly  descriptive  of  the  re- 
semblance of  the  cyst  wall,  when  exposed  at  operation,  to  a  frog's 
belly  (Skillern,  1919).     Though  occasionally  congenital,  in  the  vast 


SURGERY  OF  THE  TONGUE 


693 


majority  of  cases  it  is  acquired;  usually  it  is  considered  a  retention 
cyst  of  one  of  the  sublingual  glands  or  its  duct,  but  it  may  be  a 
hydrops  of  the  sublingual  bursa  of  Fleischmann  (1841).  The  cyst 
in  most  cases  is  of  slow  development  and  chronic  in  duration.  It 
is  unilocular.  Conditions  described  as  acute,  and  as  intermittent 
ranula  are  also  recognized,  though  very  rare.  In  the  acute  cases 
a  swelling  suddenly  appears  beneath  the  tongue,  the  mucous  mem- 
brane lining  the  floor  of  the  mouth  is  raised  above  the  dental 
border,  salivation  is  profuse, 
speech,  deglutition,  and  even 
respiration  are  interfered  with, 
and  suffocation  may  threaten. 
Astringent  washes  usually  are 
sufficient  to  relieve  the  symp- 
toms, and  the  cystic  swelling 
may  disappear  as  rapidly  as  it 
came,  as  was  the  case  in  the 
only  patient  with  this  rare  af- 
fection I  have  seen;  but.  some- 
times incision  is  required.  In 
the  chronic  cases  the  cyst, 
though  unilateral  at  first,  may 
spread  so  as  to  involve  the 
entire  sublingual  region;  very 
seldom  at  the  present  day  is 
it  allowed  to  grow  so  large  as  to  project  in  the  submental  region. 
The  mucous  membrane  slides  freely  over  it,  and  its  surface  often  is 
covered  with  dilated  and  tortuous  veins  (Fig.  772) ;  it  is  semi-trans- 
lucent, and  the  contents  are  a  viscid,  ropy  fluid.  Ranula  is  most 
likely  to  be  confounded  with  dermoid  cysts,  which,  however,  are  rare; 
a  dermoid  cyst  has  thicker  walls,  pits  on  pressure,  and  is  not  trans- 
lucent. 

Treatment. — Excision  of  the  anterior  wall  of  the  cyst,  and  scraping 
or  cauterizing  the  remaining  portion  of  the  lining  membrane,  and 
packing  the  cavity  with  gauze  until  healing  by  granulation  takes 
place,  usually  effect  a  cure.  But  unless  a  thorough  operation  is  done 
and  the  after-treatment  efficiently  conducted,  recurrence  will  take 
place.  The  operation  can  be  done  under  local  anesthesia,  through 
the  mouth. 

Ludwig's  Angina,  or  Angina  Ludovici,  is  a  condition  first  accurately 
described  by  Ludwig  in  1834.  It  is  an  acute  septic  inflammatory 
process  involving  the  cellular  tissues  of  the  floor  of  the  mouth  and  the 
submaxillary  region  of  one  or  both  sides  of  the  neck.  It  is  important  to 
note  that  in  this  definition  the  main  clinical  features  of  the  disease  are 
indicated.  It  affects  the  connective  tissue  spaces,  being  a  cellulitis, 
as  asserted  by  G.  G.  Davis  (1906),  not  a  lymphangitis;  the  lymph 
nodes  and  the  submaxillary  and  sublingual  salivary  glands  are  not 
primarily  diseased,  but  may  be  invaded  secondarily.    It  involves  both 


Fig.  772. — Ranula.  Age  eleven  years; 
duration  over  one  year.  Projecting  cyst  is 
dark  blue  from  overlying  vein.  Episcopal 
Hospital. 


694  SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 

the  floor  of  the  mouth  and  the  cervical  tissues.  It  is  not  confined  to 
either.  Usually  it  owes  its  origin  to  infection  from  dental  lesions, 
and  often  commences  after  the  extraction  of  teeth;  but  it  may  begin 
in  the  tonsil  or  other  intrabuccal  structure.  The  cellulitis  spreads 
with  great  rapidity  from  the  floor  of  the  mouth  around  the  posterior 
border  of  the  mylo-hyoid  muscle,  a  route  to  which  attention  was 
called  by  T.  T.  Thomas  in  1907.  Both  sides  of  the  neck  are  affected. 
The  submaxillary  gland  and  lymph  nodes  usually  are  found  more  or 
less  intact  in  the  center  of  a  necrotic  area  of  cellular  tissue. 

It  is  not  unusual  for  groups  of  patients  to  be  affected  nearly  simul- 
taneously, but  the  disease  does  not  seem  to  be  contagious. 

Symptoms. — The  onset  of  the  disease  is  marked  usually  by  difficulty 
in  talking  and  swallowing,  pain  in  the  floor  of  the  mouth,  salivation, 
and  finally  dyspnea.  The  patient  becomes  profoundly  septic,  but 
gives  evidences  of  little  or  no  constitutional  reaction.  The  tempera- 
ture often  is  not  very  high,  nor  is  there  marked  leukocytosis.  Edema 
of  the  glottis  may  occur  at  any  time,  and  T.  T.  Thomas  believes  this 
is  the  usual  cause  of  death;  but  in  many  cases  death  seems  to  be  due 
to  toxemia,  and  suffocative  symptoms  are  entirely  absent. 

Diagnosis. — The  diagnosis  depends  on  recognizing  a  possible  cause; 
on  demonstrating  a  cellulitis  both  in  the  floor  of  the  mouth  and  in  the 
upper  cervical  regions,  perhaps  extending  to  the  clavicle,  and  often 
more  marked  on  one  side;  and  on  the  rapid  progress  of  the  disease 
to  a  fatal  termination  unless  relieved  by  efficient  treatment. 

Treatment. — As  soon  as  the  diagnosis  is  made,  and  without  waiting 
for  the  development  of  more  serious  symptoms,  the  parts  should  be 
incised.  This  may  be  done  under  local  anesthesia;  general  anesthesia 
may  be  out  of  the  question,  owing  to  the  suffocative  symptoms.  An 
incision  is  made  directly  in  the  median  line  in  the  submental  region, 
between  the  geniohyoid  muscles;  the  knife  is  pushed  up  into  the  floor 
of  the  mouth,  emerging  just  behind  the  symphysis  menti.  There  are 
no  structures  of  importance  in  the  median  line.  A  drainage  tube  is 
then  drawn  through  from  the  submental  region  to  the  floor  of  the  mouth. 
An  incision  is  then  made  in  one  or  both  submaxillary  regions,  and  a 
tract  is  made  by  thrusting  a  hemostat  into  the  mouth  through  the 
mylohyoid  muscle  or  around  its  posterior  border.  Tubes  are  then 
inserted  in  these  additional  tracts;  or  one  long  tube  may  be  made  to 
pass  from  one  submaxillary  region  to  the  other  across  the  floor  of  the 
mouth  above  the  mylohyoid  muscle  (Fig.  773).  In  addition,  if  the 
sublingual  tissue  is  markedly  edematous,  it  is  well  to  incise  the  mucous 
membrane  of  the  floor  of  the  mouth  from  the  midline  to  the  second 
molar  tooth,  as  advised  by  J.  W.  Price  (1908),  and  gently  to  curette 
wherever  a  soft  spot  is  found.  Usually  little  or  no  pus  is  found,  the 
infection  being  so  severe  that  the  tissues  are  unable  to  react.  The  parts 
are  dressed  with  hot,  moist  antiseptic  gauze,  to  form  a  poultice.  Con- 
centrated nutriment  and  stimulants  should  be  given.  Tracheotomy 
is  required  when  edema  of  the  glottis  occurs.  The  mortality  of  the 
affection  has  varied  from  20  to  40  per  cent,  in  different  series  of  cases. 


SURGERY  OF  THE  TONGUE 


695 


Fig.  773. — Ludwig's  angina,  in  a 
patient  of  twenty-two  years.  After 
operation.  (Dr.  J.  W.  Price,  Jr.'s 
case.)     Episcopal  Hospital. 


Glossitis.  —  Acute  Superficial  Glossitis  may  follow  burns,  scalds,  or 
other  injuries,  and  the  lesion  may  be  catarrhal  in  character,  or  associated 
with  destruction  of  the  mucous  mem- 
brane and  the  formation  of  one  or 
more  ulcers.  Stomatitis  of  similar 
form  may  coexist.  Healing  readily 
occurs,  as  a  rule,  under  the  influence 
of  alkaline  mouth  washes.  An  indo- 
lent ulcer  may  be  touched  with  a 
drop  of  pure  carbolic  acid. 

Acute  Parenchymatous  Glossitis,  in 
which  the  tongue  suddenly  becomes 
immensely  swollen,  threatening  suffo- 
cation, is  described  by  systematic 
writers.  It  is  an  infectious  process, 
analogous  to  but  rarer  than  Lud- 
wig's angina,  and  not  affecting  the 
sublingual  nor  the  cervical  tissues. 
Treatment  consists  in  incising  the  dor- 
sum of  the  tongue  to  the  depth  of  5 
to  10  mm.,  each  side  of  the  median 
raphe,  for  a  distance  of  about  5  cm. 
This  rapidly  relieves  the  swelling. 

Abscess  of  the  Tongue  may  be  acute  or  chronic.  Either  form  is  rare, 
and  the  chronic  form  may  be  indistinguishable  from  a  deep  gumma 
of  the  tongue.  If  fair  trial  of  antisyphilitic  treatment  causes  no 
improvement,  an  exploratory  incision  should  be  made.  Incision  is 
the  proper  treatment  also  for  acute  abscess. 

Chronic  Superficial  Glossitis  is  known  by  various  other  names,  more 
or  less  descriptive  of  different  stages  of  the  disease.  The  best  known 
and  most  used  is  Leukoplakia .  Other  names  are  Leukoma,  Leuko- 
keratosis,  Smokers'  Patches,  Psoriasis,  and  Ichthyosis  of  the  Tongue. 
These  conditions  derive  their  surgical  importance  from  the  fact  that 
they  are  recognized  as  precancerous  diseases,  analogous  to  the  senile 
keratosis  of  the  skin  discussed  at  page  669.  The  pathological  change 
in  the  tongue  consists  in  a  proliferation  of  the  epithelial  cells,  col- 
lection of  leukocytes,  and  scar  formation  immediately  beneath  the 
epithelial  layer.  The  patches  may  occur  on  the  tongue  alone,  on  the 
cheeks  and  lips  alone,  or  on  both  tongue  and  other  buccal  surfaces. 
They  are  seen  oftenest  on  the  dorsum  of  the  tongue  near  its  tip,  but 
not  in  the  median  line.  They  never  occur  behind  the  circumvallate 
papillae.  They  may  be  small  or  large,  irregular,  circular,  circinate,  or 
"geographical"  in  outline;  they  always  spread,  and  different  patches 
frequently  coalesce.  Early  in  the  disease  the  patches  appear  as  red, 
shiny,  smooth  areas  on  the  tongue,  surrounded  by  a  distinctly  furred 
area  of  mucous  membrane  (Smokers'  Patches).  Later  these  patches 
become  bluish  white,  but  retain  their  characteristic  smoothness 
(Leukoplakia).     Still  later  some  evidences  of  thickening  and  indura- 


696  SURGERY  OF  THE  FACE,   MOUTH,  AND  NECK 

tion  are  present,  the  patches  are  furrowed,  and  the  fissures  may  be 
ulcerated  (Leukokeratosis).  This  stage  borders  on  the  development 
of  carcinomatous  changes. 

Cause. — The  cause  of  this  affection  is  not  known,  but  is  definitely 
related  to  several  forms  of  chronic  irritation.  Of  these  the  most  impor- 
tant is  smoking  or  the  use  of  tobacco  in  any  form;  probably  it  is  the 
chemicals  in  the  tobacco,  combined  with  the  mechanical  irritation, 
and,  in  the  case  of  smoke,  the  heat,  that  renders  its  use  so  harmful. 
But  many  cases  occur  in  those  who  have  never  used  tobacco.  Other 
predisposing  causes  are  syphilis,  when  its  tertiary  stage  is  reached; 
psoriasis,  or  ichthyosis,  elsewhere  in  the  body;  the  presence  of 
broken,  or  decayed  teeth;  irritation  from  baldy  fitting  dental  plates,  etc. 

Symptoms. — The  earliest  symptom,  which  may  be  overlooked  for 
many  months,  is  smarting  in  the  tongue  after  excessive  smoking  or 
drinking;  later,  pain  is  felt  whenever  highly  seasoned  or  hot  food  is 
taken.  But  the  patient  may  discover  the  patches  accidentally,  on 
looking  in  the  mirror;  or  they  may  be  called  to  his  attention  by  his 
dentist  or  physician  before  any  definite  symptoms  have  arisen. 

Treatment.— The  use  of  tobacco  in  any  form  should  be  absolutely 
prohibited  until  entire  disappearance  of  the  lesions.  Any  other  form 
of  irritation,  whether  due  to  dental  conditions  or  dietary  indiscretions, 
should  be  remedied,  and  unirritating,  preferably  alkaline,  mouth 
washes  should  be  ordered.  Cauterization  of  the  lesions  usually  makes 
them  worse.  If  there  is  a  single,  small,  localized  lesion,  it  may  be 
excised.  If  epithelioma  is  suspected,  a  portion  of  the  patch  should 
be  excised  for  microscopical  examination. 

Tuberculosis.— Tuberculosis  of  the  tongue  is  rare.  Scott  (1916) 
collected  231  cases,  only  26  of  which  were  primary.  The  lesion  com- 
mences as  a  tuberculoma,  but  very  seldom  is  it  seen  until  this  has 
broken  down,  leaving  an  ulcer.  The  primary  lesion  usually  is  in  the 
lungs  or  larynx,  and  this  gives  the  clue  to  the  diagnosis.  The  tuber- 
culous ulcer  appears  at  the  tip  or  edges  of  the  tongue,  rarely  on  the 
dorsum;  it  is  superficial  and  lies  in  the  long  axis  of  the  tongue;  it  is 
not  indurated;  has  not  raised  or  thickened  borders;  secretes  thick 
and  yellowish  pus;  and  may  be  surrounded  by  caseous  foci.  It  is 
commonest  in  men  and  in  adults  (Plate  IX,  Fig.  1).  The  ulcer  is  very 
painful.    Early  invasion  of  the  cervical  lymph  nodes  is  usual. 

Treatment. — In  the  very  rare  cases  where  tuberculosis  is  primary 
in  the  tongue  it  is  proper  to  excise  the  lesion  together  with  the  enlarged 
lymph  nodes.  In  most  cases,  however,  nothing  can  be  done  save  to 
relieve  the  pain  by  local  use  of  cocain  or  other  anesthetic.  Armstrong 
says  spraying  the  affected  area  with  a  1  per  cent,  solution  of  carbolic 
acid,  to  which  a  little  sodium  bicarbonate  has  been  added,  sometimes 
is  soothing. 

Syphilis. — Syphilis  of  the  tongue  is  of  most  surgical  interest  in  the 
gummatous  stage.  Chancre  and  mucous  patches  of  the  tongue  and 
mouth  present  the  same  characteristics  as  these  lesions  elsewhere, 
and  their  diagnosis  seldom  is  difficult.     Gumma  of  the  tongue  may  be 


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3 

SURGERY  OF  THE  TONGUE  697 

single  or  multiple,  superficial  or  deep.  The  lesions  occur  chiefly  on 
the  dorsum  of  the  organ;  they  soon  break  down,  and  are  apt  to  coalesce, 
forming  large  irregular,  nearly  painless  ulcers  with  overhanging  edges 
and  covered  with  an  adherent  slough.  The  ulcers  do  not  tend  to 
bleed  when  the  slough  is  pulled  away;  they  are  not  indurated;  they  are 
not  accompanied  or  followed  by  enlargement  of  the  cervical  lymph 
nodes;  a  history  of  previous  syphilitic  lesions  usually  can  be  obtained; 
and  they  rapidly  improve  under  the  administration  of  the  iodides. 
These  features  serve  to  distinguish  them  from  carcinomatous  ulcers 
(p.  698).  Diffuse  gummatous  glossitis  as  it  heals  leaves  a  charac- 
teristically fissured  and  furrowed  tongue  (Plate  IX,  Fig.  2). 

Benign  Tumors  of  the  tongue  occasionally  arise  in  the  lingual  tonsil. 
They  should  be  excised  before  malignancy  develops. 

Sarcoma. — Sarcoma  of  the  tongue  is  very  rare.  Coughlin  (1915) 
collected  60  cases. 

Carcinoma. — In  the  tongue  this  occurs  almost  invariably  in  the 
form  of  epithelioma,  though  a  few  cylindrical-celled  carcinomas  have 
been  recorded.  It  is  much  more  common  in  men  than  in  women 
(about  15  to  1),  and  quite  unusual  before  middle  life.  Frequently  it 
seems  to  be  brought  on  by  chronic  irritation,  such  as  that  from  a 
broken  tooth,  from  tobacco  smoke,  or  the  stem  of  a  pipe  (Plate  IX, 
Fig.  3) .  The  pre-cancerous  lesions  of  the  tongue  already  have  been 
discussed  (p.  695),  and  Butlin  demonstrated  not  long  ago  that  many 
lesions,  previously  considered  by  him  and  others  as  pre-cancerous, 
prove  on  microscopical  examination  to  be  actually  malignant. 

Usually  the  epithelioma  begins  in  a  fissure,  an  ulcer,  or  a  patch  of 
leukoplakia.  Sometimes,  but  rarely,  it  appears  first  as  a  wart  or 
papilloma;  and  any  such  growth  on  the  tongue  which  does  not  disap- 
pear very  promptly  after  removal  of  a  recognized  source  of  irritation 
should  be  considered  malignant.  The  epithelioma  commonly  appears 
on  the  lateral  margin  of  the  tongue,  very  rarely  at  the  tip,  and  almost 
never  on  the  dorsum.  It  begins  occasionally  as  a  submucous  growth, 
but  even  in  such  cases  it  is  very  seldom  seen  until  an  ulcer  has  formed; 
and  in  the  vast  majority  of  instances  it  develops  in  a  preexisting 
erosion  or  ulcer.  It  may  begin  in  the  floor  of  the  mouth,  but  it  is 
more  usual  for  this  to  be  invaded  secondarily.  A  cancer  in  the  ante- 
rior third  of  the  tongue  tends  to  spread  to  the  floor  of  the  mouth  and 
mucous  membrane  covering  the  alveolus;  it  early  invades  the  sub- 
mental and  submaxillary  lymph  nodes,  first  those  on  the  same  side  as 
the  growth,  but  later  the  involvement  is  bilateral.  Next  the  deep 
cervical  chain  is  invaded.  The  submaxillary  and  sublingual  salivary 
glands  usually  are  not  invaded.  A  cancer  in  the  posterior  two-thirds 
of  the  tongue  tends  to  spread  to  the  soft  palate  and  pharynx;  it  invades 
the  lymphatics  of  both  sides  very  early;  first  the  submaxillary,  then 
the  deep  cervical.  When  the  latter  have  been  invaded  by  cancer 
arising  in  any  part  of  the  tongue,  the  growth  spreads  up  their  chain 
to  the  base  of  the  skull  and  downward  to  the  clavicle.  Distant 
metastases  occur  very  late   and    are  quite   unusual.     In    the    vast 


cm 


SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 


majority  of  cases  the  disease  is  distinctly  limited  to  the  face  and  neck. 
When  once  the  cervical  lymph  nodes  are  invaded,  the  tumor  may 
grow  in  them  with  alarming  rapidity,  and  these  secondary  growths 
may  quite  over-shadow  the  original  trouble.  The  same  progressively 
fatal  course,  but  even  more  rapidly,  is  observed  here  as  in  the  cervical 
growths  following  carcinoma  of  the  lip  (p.  G89). 

Symptoms.  Tain  and  smarting  in  the  diseased  area,  especially 
on  smoking,  drinking  alcoholic  beverages,  or  eating  hot  or  highly 

seasoned  food,  usually  are  the 
first  things  to  attract  the  patient's 
attention.  The  tongue,  or  the 
whole  mouth,  may  feel  sore. 
There  is  difficulty  and  pain  in 
swallowing,  and  the  patient 
refrains  from  eating.  Later 
even  liquids  can  scarcely  be 
taken.  The  tongue  feels  thick 
and  clumsy.  Speech  becomes  in- 
distinct. Salivation  is  increased. 
Pain  may  be  referred  to  the  ear 
if  the  growth  is  far  back  in  the 
tongue.  Very  rarely  is  pain  al- 
together absent;  but  occasionally 
the  patient  is  unaware  of  his 
condition  until  the  tumor  is 
inoperable.  From  inability  to 
eat,  sleepless  nights,  and  constant  pain,  the  patient  rapidly  becomes 
emaciated.  If  secondary  infection  occurs,  there  will  be  added  fever- 
ishness,  chilliness,  and  increased  secretion  from  the  tumor,  with  hor- 
rible fetor  of  the  breath.  Hemorrhages  may  occur  from  the  mouth 
or  from  secondary  ulcers  in  the  neck.  Death  may  occur  from  such  a 
complication  or  from  septic  inhalation  pneumonia,  but  more  often 
follows  a  short  period  of  delirium  due  to  toxic  absorption. 

Diagnosis.— Carcinoma  of  the  tongue  must  be  distinguished  chiefly 
from  tuberculous  and  syphilitic  ulcerations.  The  characteristics  of 
these  have  been  considered  already  (p.  696);  but  it  should  not  be 
forgotten  that  carcinoma  frequently  develops  in  a  syphilitic  lesion. 
In  carcinoma  the  main  diagnostic  points  are  the  hardness  of  the 
ulcer's  base;  the  thickness  of  its  margins,  the  bleeding  when  the  adher- 
ent slough  is  removed,  exposing  an  uneven  floor;  the  patient's  age; 
and  the  existence  of  some  chronic  form  of  local  irritation.  Any  ulcer 
even  suspected  of  being  carcinomatous  should  be  subjected  to  micro- 
scopical study.  A  portion  of  the  ulcer  may  be  removed  easily  by 
pulling  the  tongue  far  out  of  the  mouth  and  injecting  some  eucain 
solution  beneath  the  ulcer;  a  'portion  of  the  indurated  margin  of  the  ulcer 
is  then  pinched  up  in  forceps  and  cut  off  with  scissors.  Enlargement  of 
the  lymph  nodes  never  should  be  depended  upon  for  a  clinical  diagnosis. 
Long  before  they  are  palpable  they  are  microscopically  diseased.    Yet 


Fig.  774. — Recurrent  carcinoma  of  floor 
of  mouth.  Excision  of  tongue  by  intra- 
buccal  method  in  September,  1909,  three 
months  after  appearance  of  growth.  Re- 
currence in  November,  1909.  Photograph 
February  14,  1910.  (Dr.  H:  C.  Deaver's 
case.)     Episcopal  Hospital. 


SURGERY  OF  THE  TONGUE  699 

the  presence  of  enlarged  lymph  nodes  points  to  carcinoma  rather  than 
to  a  tertiary  syphilitic  lesion. 

Prognosis. — In  cases  entirely  untreated,  the  expectation  of  life  is 
not  more  than  eighteen  months  from  the  time  the  growth  is  recog- 
nized. In  many  cases  death  occurs  in  less  than  nine  months.  By 
radical  surgical  treatment  the  expectation  of  life  is  almost  doubled, 
and  a  certain  number  of  patients  (25  per  cent,  in  Butlin's  statistics) , 
in  whom  early  operation  is  done,  remain  free  of  recurrence  for  many 
years  or  until  death  from  some  other  malady.  Even  in  cases  where 
recurrence  takes  place,  this  is  almost  always  in  the  neck,  and  the 
patient  is  still  able  to  take  nourishment  and  does  not  suffer  nearly  so 
much  pain  as  if  the  tumor  was  still  growing  in  the  mouth.  The  imme- 
diate mortality  after  radical  operation  is  in  general  from  15  to  20  per 
cent.  It  is  lower  in  uncomplicated  cases,  and  much  higher  when  part 
of  the  mandible  or  pharynx  has  to  be  removed. 

Treatment.— Owen  well  said  (1908)  that  most  of  these  patients  come  to 
the  surgeon  when  the  tumor  is  so  far  advanced,  that  if  he  considered  only 
his  own  peace  of  mind  he  would  decline  to  undertake  any  operation. 
But  whenever  it  is  not  inoperable,  radical  removal  of  the  growth  and 
the  related  lymph  nodes  is  the  only  rational  treatment.  In  deciding 
for  or  against  operability,  the  surgeon  should  examine  especially  the 
local  extent  of  the  disease,  and  the  range  of  lymphatic  involvement. 
A  cancer  of  the  tongue  cannot  be  considered  inoperable  merely  because 
it  has  invaded  the  floor  of  the  mouth  or  has  eaten  into  the  mandible. 
But  if  the  entire  floor  of  the  mouth,  on  both  sides,  is  densely  infiltrated, 
and  especially  if  the  growth  has  extended  along  the  anterior  pillar 
of  the  fauces  to  the  soft  palate  or  pharynx,  it  generally  will  be  impos- 
sible to  cut  wide  enough  of  the  growth  to  ensure  freedom  from  local 
recurrence.  In  regard  to  lymphatic  involvement,  the  surgeon  should 
examine  carefully  and  repeatedly  the  deep  cervical  lymphatics  extend- 
ing up  to  the  base  of  the  skull.  If  these  are  manifestly  involved,  and 
certainly  if  they  are  immovably  adherent  to  the  spinal  muscles  or  the 
skull  itself,  he  should  decline  to  interfere  with  them.  Involvement 
of  the  lymphatics  downward  is  not  so  serious  a  matter,  since  it  is 
very  seldom  that  the  disease  process  passes  beyond  the  subclavian 
triangle;  and  the  contents  of  this  triangle  and  those  above  it  can  be 
removed  with  comparative  facility  by  modern  methods. 

Most  surgeons  prefer  to  do  in  two  stages  whatever  form  of^operation 
is  undertaken  and  if  the  disease  is  advanced,  this  is  the  only  safe  plan. 
Usually  the  lingual  growth  is  removed  first;  and  after  a  week  or  ten 
days  the  cervical  lymphatics  are  dissected  out.  In  early  cases  (3  to  5 
months'  duration)  it  may  be  sufficient  to  remove  the  lymphatics  only 
from  the  bifurcation  of  the  carotid  up  to  the  tongue  and  base  of  the 
skull ;  in  more  advanced  cases  the  dissection  must  commence  as  low  as 
the  clavicle.  If  only  the  anterior  third  of  the  tongue  is  involved,  most 
surgeons  consider  it  sufficient  to  remove  the  submental  nodes  and  the 
cervical  nodes  of  the  same  side  as  the  lingual  lesion;  but  Da  Costa  (1908) 
urged  that  even  in  such  cases  the  cervical  lymphatics  also  on  the  other 


700  SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 

side  should  be  excised,  as  he  had  found  them  involved  at  a  very  early 
stage.  Nearly  all  authorities  are  agreed  that,  when  the  tumor  involves 
the  posterior  part  of  the  tongue,  the  lymphatics  from  both  sides  of  the 
neck  ought  to  be  removed.  This  may  require  the  division  of  the  opera- 
tion into  three  stages.  Owen  recommends,  if  the  lymph  nodes  are 
increasing  very  rapidly  in  size,  that  the  first  operation  should  consist 
in  extirpating  them,  since  if  the  tongue  is  removed  first,  and  the  opera- 
tion on  the  lymph  nodes  postponed  for  a  couple  of  weeks,  they  may  have 
become  inoperable  by  that  time. 

The  questions  of  the  preparation  of  the  patient  and  of  the  anesthetic 
are  of  importance.  For  several  days  previously  special  attention 
should  be  given  to  cleansing  the  patient's  mouth,  and  improving  so 
far  as  possible,  his  general  health.  No  operation  should  be  done  while 
there  is  an  acute  bronchial  or  pulmonary  lesion.  The  anesthetic, 
preferably  ether,  should  be  given  by  a  skilled  anesthetist;  wherever 
possible  (and  this  should  be  the  case  in  every  well  appointed  hospital) 
the  method  of  intratracheal  insufflation  (p.  155)  should  be  employed. 
This  minimizes  or  altogether  prevents  the  chance  of  pulmonary  com- 
plications, and  permits  the  operation  to  be  done  in  the  head-high 
position,  which  markedly  decreases  the  quantity  of  blood  lost.  If 
this  method  cannot  be  used,  one  of  the  other  methods  recommended 
at  p.  155  for  operations  on  the  head  and  neck  should  be  employed. 
A  hypodermic  of  morphin  and  atropin  should  be  given  shortly  before 
beginning  the  operation. 

For  early  cases  the  operation  I  described  in  1915,  is  suitable;  it  is 
based  on  Crespi  and  Bastianelli's  modification  (1890)  of  Langenbeck's 
method  (1875):  (a)  The  cervical  lymphatics  are  first  removed  on  the 
diseased  side  through  an  incision  passing  from  the  chin  to  the  hyoid 
bone,  and  thence  to  the  mastoid,  well  below  the  body  of  the  mandible 
(Fig.  775) .  By  well  undermining  this  incision  a  much  larger  area  of  fat 
and  lymphatics  can  be  reached.  The  branches  of  the  external  carotid 
are  ligated,  but  the  descendens  hypoglossi,  the  hypoglossal,  the  superior 
laryngeal  and  spinal  accessory  nerves  are  carefully  preserved.  When 
the  entire  area  has  been  cleared,  the  skin  flap  is  turned  over  the  cheek 
(Plate  X,  Fig.  1)  and  the  mass  of  fat  and  lymphatics  is  removed. 
(6)  A  suture  is  passed  through  the  tip  of  the  tongue,  and  a  mouth  gag  is 
inserted  on  the  opposite  side  of  the  mouth.  The  original  skin  incision 
is  then  continued  from  the  chin  up  through  the  lower  lip;  this  is  detached 
from  the  alveolus,  and  the  cheek  is  turned  aside.  Another  traction 
suture  is  now  passed  through  the  glosso-epiglottidean  fold,  and  both 
this  and  the  suture  through  the  tongue  are  drawn  taut.  Next  the 
frenum  and  the  mucosa  between  tongue  and  alveolus,  and  the  anterior 
pillars  of  the  fauces  are  divided;  the  tongue  can  now  be  pulled  far 
forward,  and  its  base  and  the  muscles  still  holding  it  to  the  hyoid  bone, 
can  be  cut  under  full  visual  control  (Plate  X,  Fig.  2).  The  lingual 
artery  on  the  opposite  side  will  bleed  in  the  stump  of  the  tongue,  and 
require  ligation  (Fig.  776).  Molar  teeth  on  the  diseased  side  are  then 
extracted,  and  the  corresponding  alveolus  is  cleared  of  mucous  mem- 


SURGERY  OF  THE  TONGUE 


701 


Fig.  775. — Skin  incision  for  excision  of  the  tongue.     University  of  Pennsylvania. 


Fig.  776. — After  removal  of  tongue,  the  floor  of  the  mouth  is  covered  partially  by 
suturing  the  mucosa  of  cheek  across  the  alveolus  to  stump  of  tongue.  A  hemostat  is  on 
the  right  lingual  artery  in  the  floor  of  the  mouth.     University  of  Pennsylvania. 


702 


SURGERY  OF  THE  FACE,   MOUTH,  AND  NECK 


brane  or  excised;  this  permits  the  mucosa  on  the  buccal  surface  of  the 
cheek  to  be  drawn  in  as  a  flap  and  sutured  across  the  denuded  alveolus 


Fig.  777. — Skin  incision  sutured;  drainage  tube  in  place.  Suture  through  glosso- 
epiglottidean  fold  retained  for  first  twenty-four  to  thirty-six  hours.  University  of 
Pennsylvania. 

to  the  stump  of  the  tongue  (Fig.  776),  thus  rendering  a  bucco-cervical 
fistula  less  likely.    The  remaining  portion  of  the  stump  of  the  tongue  is 


Figs.  778  and  779. — Excision  of  tongue  by  method  illustrated  in  Plate  X,  eight  months 
after  operation.  Death  from  intercurrent  disease,  without  recurrence,  nearly  four  years 
after  operation.     Episcopal  Hospital. 

sutured  to  whatever  mucosa  remains  in  the  floor  of  the  mouth;   the 
cheek  is  reattached  to  the  mandible,  and  the  lip  and  neck  wound  are 


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SURGERY  OF  THE  TONGUE 


703 


accurately  sutured,  with  tube  drainage  from  below  the  floor  of  the  mouth 
to  the  most  dependent  portion  of  the  incision  (Fig.  777).  The  resulting 
scar  is  inconspicuous  (Figs.  778 
and  779) .  If  the  lymph  nodes  re- 
moved are  found  to  have  been  in- 
vaded by  carcinoma,  those  on  the 
opposite  side  of  the  neck  are  to  be 
removed  after  two  or  three  weeks' 
interval. 

For  more  advanced  cases,  the 
cervical  lymph  nodes  must  be  re- 
moved all  the  way  down  to  the 
clavicle,  and  always  on  both  sides 
of  the  neck.  The  incisions  shown 
in  Fig.  780  are  suitable  for  this 
purpose;  the  two  sides  should  be 
operated  on  at  an  interval  of 
three    or   four   weeks;    first   the 

triangle  a  b  c  is  turned  up,  and  when,  working  from  below  upward, 
the  submaxillary  and  submental  regions  are  reached,  the  incisions 
a  d  and  a  e  are  added,  and  very  full  exposure  secured  by  elevating  the 


Fig. 


780. — -Incisions  for  extirpation  of  the 
cervical  lymphotics.     See  text. 


A  B 

Fig.  781. — Inoperable  carcinoma  of  floor  of  mouth,  after  its  arrest  by  cauterization  and 
by  excision  of  both  sternomastoid  muscles  and  lymph  nodes  on  both  sides  of  neck, 
through  incisions  shown  in  Fig.  780.  Death  from  exhaustion  fifteen  months  after 
operation.     Episcopal  Hospital. 


large  flap  e  ab  c  and  the  smaller  flaps  d  a  e  and  dab.  In  such  cases  all 
the  fat  and  lymphatic  tissues,  in  one  mass  with  the  sternomastoid 
muscle    (Fig.  781),  are  excised,  clamping  temporarily  the  common 


704  SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 

carotid  artery  low  in  the  neck,  and  if  necessary  excising  the  internal 
jugular  vein.  Even  the  vagus  nerve  and  the  common  carotid  may  be 
extirpated  on  one  side  if  necessary;,  but  in  those  past  fifty  years  of  age 
loss  of  the  common  carotid  is  inadvisable  on  account  of  the  danger  of 
cerebral  complications.  The  tongue  may  be  removed  at  the  same  time 
that  the  first  side  of  the  neck  is  being  cleared  by  extending  the  incision  ad 
through  the  lower  lip,  and  turning  the  cheek  aside,  as  in  the  method 
just  detailed. 

Other  methods  of  excision  of  the  tongue  are  in  current  use: 

1.  I iiira1>urc(il  Method  (Whitehead,  1881). — After  dividing  the  frenum, 
the  anterior  pillars  of  the  fauces,  and  the  mucosa  covering  the  floor 
of  the  mouth,  the  tongue  can  be  pulled  far  out  of  the  mouth  (Roux, 
1839);  it  is  then  cut  away,  wide  of  the  growth,  and  the  lingual  arteries 
are  caught  by  hemostats  in  the  floor  of  the  mouth,  and  the  dorsales 
lingiue  are  caught  in  the  stump. 

2.  Method  by  Division  of  the  Symphysis  Menti. — This  operation 
was  introduced  by  Sedillot  (1844)  and  a  few  years  later  by  Syme. 
Kocher  adopted  it  as  his  normal  method.  It  is  used  for  removal 
of  the  entire  tongue  in  cases  where  the  floor  of  the  mouth  is  involved. 
The  lower  lip  is  divided  in  the  mid-line,  and  this  incision  is  carried 
down  to  the  hyoid  bone.  The  mandible  is  then  drilled  in  two  places 
on  each  side  of  the  mid-line,  to  facilitate  its  subsequent  wiring.  The 
symphysis  is  then  sawed  through,  and  the  halves  of  the  mandible 
are  separated.  Rough  handling  may  cause  a  fracture.  The  mucous 
membrane  on  the  floor  of  the  mouth  is  then  divided,  the  lingual  arteries 
are  caught  and  tied,  and  the  tongue,  with  as  much  of  the  floor  of  the 
mouth  as  necessary,  is  removed  in  one  mass.  The  stump,  with  the 
two  spurting  dorsales  linguse  arteries,  is  treated  as  in  Whitehead's 
method,  over  which  this  operation  presents  few  advantages.  The 
exposure  is  not  very  much  better,  the  wound  left  is  very  prone  to 
infection,  and  the  jaw  frequently  fails  to  unite  solidly. 

When  it  is  necessary  to  excise  a  portion  of  the  mandible  along  with 
the  tongue  and  the  floor  of  the  mouth,  Crespi  and  Bastianelli's  modifi- 
cation (1890)  of  Langenbeck's  method  (1875)  is  to  be  preferred. 
After  clearing  the  cervical  region,  as  already  described,  and  turning 
aside  the  cheek,  the  mandible  is  divided  well  in  front  of  and  behind 
the  growth,  and  the  tongue  and  floor  of  the  mouth  are  removed  in  one 
piece  with  it.  For  cancer  arising  in  or  involving  secondarily  the  floor 
of  the  mouth,  temporary  division  of  the  mandible  between  the  second 
and  third  molar  teeth,  as  in  Langenbeck's  original  method,  may  be 
necessary,  even  when  the  bone  itself  is  not  invaded  by  cancer.  To 
remedy  the  defect  in  the  floor  of  the  mouth,  the  mucous  lining  of  the 
cheek  should  be  turned  inward  across  the  denuded  alveolus,  as  already 
advised  (p.  700). 

After  removal  of  the  tongue  the  patient  still  can  make  himself 
understood,  and  swallowing  is  not  interfered  with. 

Palliative  Operations  sometimes  are  possible,  even  when  the  disease 
is  too  far  advanced  to  afford  hope  of  cure.    The  most  important  of 


OPERATIONS  ON  THE  AIR  SINUSES  705 

these  methods  is  extirpation  of  the  external  carotid  arteries,  on  both 
sides,  as  introduced  by  Dawbarn  (1903),  to  effect  starvation  of  the 
lingual  growth.  Or  they  may  be  injected  with  paraffin.  These 
methods  are  not  applicable  to  cases  where  the  lymphatic  involve- 
ment over-shadows  the  original  growth.  Excision  of,  or  alcohol  injec- 
tions into,  the  lingual  nerves  may  alleviate  the  pain;  and  repeated 
cauterization  of  the  ulcer  in  the  mouth  may  render  life  endurable 
(Fig.  781).  Elect  ro-dessication  (for  superficial  growths)  and  electro- 
coagulation (for  deep-seated  neoplasms)  are  useful  in  similar  circum- 
stances (W.  L.  Clark,  1912;  Pfahler,  1914). 

OPERATIONS  ON  THE  AIR  SINUSES. 

The  air  sinuses  are  mucous-lined  cavities  draining  into  the  nasal 
passages,  and  like  the  middle  ear  are  prone  to  become  infected  when 
their  drainage  is  obstructed.  The  cure  of  adenoids,  deflected  septum, 
hypertrophied  turbinates,  and  other  seemingly  minor  conditions, 
therefore,  becomes  important  as  a  prophylactic  against  more  serious 
ailments.  Acute  infections  of  these  accessory  sinuses  usually  are 
treated  successfully  by  the  rhinologist  by  the  intranasal  route,  and  are 
by  no  means  so  important  surgically  as  chronic  infections,  which 
require  radical  operation  for  their  relief.  These  chronic  lesions  may 
consist  merely  of  empyema  of  the  sinus  affected,  or  there  may  be 
exuberant  granulation  tissue,  or  even  mucous  polypi.  As  all  these 
affections  are  rightly  considered  a  part  of  the  specialty  of  nose  and 
throat  diseases,  it  seems  inexpedient  to  do  more  here  than  outline  in 
the  briefest  possible  manner  the  nature  of  the  operations  at  present 
employed  in  their  treatment.  An  acute  exacerbation  of  a  chronic 
lesion  may  occur  at  any  time,  and.  may  be  quickly  fatal,  especially  in 
the  case  of  the  frontal,  ethmoidal,  and  sphenoidal  sinuses,  unless 
immediate  adequate  drainage  is  provided. 

The  diagnosis  of  chronic  sinusitis  is  not  always  easy,  but  depends 
in  large  measure  upon  persistent  discharge  of  pus,  found  by  intranasal 
examination  to  enter  the  nasal  passages  in  the  region  where  the 
suspected  sinus  normally  drains.  There  are  in  addition,  when  drain- 
age is  inefficient,  usually  headache  and  localized  tenderness.  In 
ethmoidal  disease  the  pain  usually  is  referred  to  the  bridge  of  the  nose 
and  the  eyeball;  in  sphenoidal  sinusitis  it  usually  is  between  the  eyes 
and  in  the  occipital  region;  in  frontal  sinusitis  the  pain  and  tenderness 
are  localized  to  the  region  above  the  root  of  the  nose  and  the  inner 
margin  of  the  orbital  cavity,  and  occasionally  the  pus  perforates 
anteriorly  and  forms  an  abscess  at  the  root  of  the  nose;  in  maxillary 
sinusitis  the  pain  may  be  referred  to  the  teeth,  the  nose,  or  all  over 
the  head,  but  tenderness  usually  is  localized  to  the  maxillary  bone. 

As  a  preliminary  to  all  these  operations,  preparation  of  the  nasal 

passages  by  a  course  of  conservative  treatment  is  essential  to  success. 

This  usually  comprises  removal  of  the  anterior  portion  of  the  middle 

turbinate  bone  which  almost  invariably  is  thickened  and  interferes 

45 


700  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

with  intranasal  drainage.  In  cases  of  patients  acutely  ill  it  often  is 
better  to  do  an  operation  which  is  incomplete  from  the  specialist's 
standpoint,  consisting  merely  in  securing  adequate  drainage  by  the 
most  accessible  route,  and  to  postpone  the  ideal  radical  operation  to 
another  occasion,  as  in  the  parallel  cases  of  acute  mastoiditis  (p.  079). 
Drainage  tubes  or  gauze,  employed  in  these  nasal  operations  never 
should  be  allowed  to  remain  in  place  more  than  forty-eight  hours. 
Careful  after-treatment,  preferably  conducted  by  a  rhinologist,  is 
necessary  to  complete  the  cure. 

The  maxillary  antrum  communicates  with  the  nasal  cavity  through 
its  middle  meatus,  and  the  opening  is  some  distance  above  the  floor 
of  the  sinus  so  that  drainage  is  very  imperfect.  Infection  may  follow 
nasal  disease  or  be  due  to  extension  upward  from  a  carious  tooth. 
When  conservative  measures  fail,  the  surgeon  may  break  through  the 
outer  wall  of  the  nasal  fossa,  in  the  inferior  meatus,  thus  establishing 
drainage  at  the  level  of  the  floor  of  the  antrum.  This  may  be  done  in 
emergency  by  firm  pressure  with  the  blunt  ends  of  the  blades  of  scissors 
curved  on  the  flat.  Usually  it  is  preferable  to  open  the  maxillary  sinus 
by  gouge  and  mallet  through  the  canine  fossa,  after  incising  and 
reflecting  the  mucous  membrane  and  periosteum.  A  large  opening 
in  the  outer  wall  of  the  sinus  should  be  made,  and  its  cavity  should 
be  cleared  of  polypi,  necrotic  bone,  etc.  Then  the  inner  wall  of  the 
sinus  is  broken  down  as  far  as  the  level  of  its  floor,  working  across  its 
cavity.  The  nasal  mucous  membrane  is  preserved,  is  formed  into  a 
flap  attached  along  the  floor  of  the  nose,  and  is  turned  outward  to 
cover  the  floor  of  the  maxillary  sinus,  which  is  thus  freely  drained  into 
the  inferior  meatus  of  the  nose.  This  mucous  flap  is  held  in  place  by 
packing  introduced  from  the  nasal  cavity,  and  the  incision  in  the 
alveolar  tissues  is  closed  by  suture. 

The  frontal  sinus  is  readily  exposed  by  applying  a  small  trephine 
just  to  one  side  of  the  glabella.  As  the  size  of  these  sinuses  is  extremely 
variable,  not  only  in  different  individuals,  but  also  on  the  two  sides 
of  the  same  individual,  the  surgeon  always  should  make  an  opening 
which  is  small  and  close  to  the  root  of  the  nose,  so  as  to  run  no  danger 
of  entering  the  cranial  cavity.  This  opening  may  then  be  enlarged 
with  gouge  or  rongeur.  A  tract  for  drainage  into  the  middle  meatus 
of  the  nose  can  be  made  by  enlarging  the  infundibulum  with  curette. 
Such  drainage,  by  a  tube  passed  from  the  inner  angle  of  the  frontal 
incision  down  into  the  nose,  is  sufficient  in  emergency.  Lothrop  (1915) 
to  ensure  free  drainage  and  prevent  secondary  invasion  of  the  other 
frontal  sinus,  opens  this  also  into  the  nose,  converting  both  sinuses 
into  one  large  cavity. 

The  anterior  ethmoidal  cells  frequently  are  diseased  along  with  the 
frontal  sinus,  as  they  usually  drain  into  the  upper  part  of  the  infun- 
dibulum; and  they  are  best  evacuated  across  the  opened  frontal  sinus. 
The  middle  and  posterior  ethmoidal  cells  drain  into  the  middle  meatus 
and  the  superior  meatus,  respectively.  They  may  be  reached  by  resec- 
tion of  the  os  planum,  after  exposing  the  inner  wall  of  the  orbit. 


SURGERY  OF  THE  JAWS  707 

There  may  be  a  fistula  in  this  situation,  or  even  an  abscess  between 
the  os  planum  and  the  eye-ball.  Drainage  into  the  nasal  cavity  and 
from  the  external  wound  is  provided  for.  For  radical  cure,  Killian's 
operation  is  preferable.     (See  below.) 

The  sphenoidal  sinus  seldom  can  be  drained  effectively  by  the  intra- 
nasal route,  and  as  the  ethmoidal  and  frontal  sinuses  frequently  are 
involved  also,  the  method  of  treatment  for  radical  cure  usually 
employed  now  is  that  known  as  Killian's  Operation  (1902),  which 
involves  an  approach  across  the  frontal  sinus.  This  includes  removal 
of  the  anterior  wall  of  the  frontal  sinus  and  of  its  floor  (the  roof  of  the 
inner  part  of  the  orbit),  leaving  a  bridge  of  bone  (supraorbital  ridge) 
between  these  two  openings  to  support  the  soft  parts  when  sutured 
and  thus  prevent  deformity.  After  evacuating  the  frontal  sinus,  and 
thoroughly  exposing  all  its  angles,  the  frontal  process  of  the  superior 
maxilla  is  removed.  (This  should  be  done  without  injury  to  the 
mucosa  of  the  nasal  cavity,  which  is  to  be  preserved  as  a  flap  to  line 
the  excavated  frontal  sinus  and  establish  a  free  communication 
between  this  cavity  and  the  nose.)  The  ethmoid  cells  which  are  thus 
exposed  are  then  cleaned  away,  and  the  anterior  wall  of  the  sphenoidal 
sinus  is  removed  by  gouge  or  gouge  forceps.  Removal  of  part  of  the 
nasal  bone  of  the  side  affected  may  be  necessary  to  secure  better 
exposure.  The  flap  of  nasal  mucosa  finally  is  turned  outward  across 
the  lower  wall  of  the  large  cavity,  and  this  is  lightly  packed  with  gauze 
which  emerges  into  the  nasal  fossa.  The  external  wound  is  then 
completely  sutured. 

SURGERY  OF  THE  JAWS. 

Alveolar  Abscess. — Alveolar  abscess  almost  always  is  secondary 
to  dental  disease.  Before  the  stage  of  suppuration,  peridental  inflam- 
mation is  denoted  by  tenderness,  which  usually  is  relieved  by  firm 
pressure  on  the  gum,  accompanied  by  moderate  swelling.  At  this 
stage  proper  disinfection  of  the  root  canals  of  the  teeth,  which  are 
infected  from  the  cavity  in  the  crown,  usually  causes  arrest  of  the  pro- 
cess. Later  the  entire  side  of  the  jaw  may  be  swollen,  and  tenderness 
is  exquisite.  Sometimes  the  pus  escapes  at  the  side  of  the  tooth,  but 
in  many  cases  it  spreads  beneath  the  periosteum  of  the  jaw,  and 
unless  promptly  evacuated,  osteomyelitis  and  necrosis  may  result,  or 
in  the  upper  jaw,  involvement  of  the  maxillary  sinus.  Occasionally 
the  pus  breaks  through  the  skin  below  the  body  of  the  mandible 
(Fig.  782),  or  will  form  an  abscess  in  the  cheek  (Fig.  783).  Secondary 
infection  of  the  salivary  glands  or  of  the  cervical  lymph  nodes  ma3~  occur. 

Treatment. — -Early  free  incision  of  the  alveolar  border,  down  to  the 
bone,  followed  by  detergent  mouth  washes  usually  is  promptly  curative, 
and  even  if  no  pus  is  found  this  incision  quickly  relieves  pain  and 
markedly  accelerates  recovery.    A  diseased  tooth  should  be  extracted. 

Acute  Osteomyelitis  of  the  jaws  is  not  common  even  in  the  mandible, 
and  in  the  maxilla  is  decidedly  rare.  The  general  septic  symptoms 
render  differentiation  from  alveolar  abscess  easy. 


708 


SURGERY  OF   THE  FACE,    MOUTH,    AM)   NECK 


Treatment. — Treatment  consists  in  free  incision,  both  inside  and 
outside  the  month.  The  inflammation  may  be  confined  to  the  alveolar 
border,  but  it  is  better  to  open  the  body  of  the  jaw  by  trephine  or  gouge 
if  there  is  any  doubt  as  to  the  limits  of  the  disease.     Free  drainage 

is  the  most  essential  factor. 


W'  '"        ^"S 

M« 

"^B 

7^| 

i^| 

fv^  ^    ^Sa 

Fig.  782. — Alveolar  abscess  of  lower 
jaw,  pointing  over  body  of  mandible. 
Four  days  after  extraction  of  tooth. 
Episcopal  Hospital. 


Fig.  783. — Abscess  of  left  cheek,  fol- 
lowing pulling  of  teeth  on  upper  and 
lower  jaw,  thirteen  days  previously. 
Episcopal  Hospital. 


Necrosis  of  the  Jaws  affects  the  mandible  in  most  cases,  and  follows 
acute  osteomyelitis,  or  may  be  due  to  phosphorus  poisoning,  with 
subacute  or  chronic  onset.  In  the  latter  instance  the  disease  seldom 
appears  until  the  patient  has  been  working  in  phosphorus  for  several 
years,  and  it  may  not  appear  for  several  years  after  the  patient  has 
quit  his  work  in  phosphorus.  Phosphorus  poisoning  produces  changes 
of  a  chronic  ossifying  nature  in  the  periosteum  in  all  parts  of  the 
body,  resulting  in  increased  density  of  the  bone,  decrease  in  the 
size  of  the  marrow  cavity,  and  lessened  circulation.  These  changes 
are  particularly  marked  in  the  mandible.  If  secondary  infection  does 
not  intervene,  as  in  the  mandible  it  usually  does  from  carious  teeth, 
the  later  stages  of  the  process  (rarefaction  and  pathological  fracture) 
are  seen.  Workers  in  phosphorus  should  have  their  teeth  inspected 
and  cleaned  by  a  competent  dentist,  at  frequent  intervals.  Necrosis 
of  the  jaws  occasionally  results  from  the  constitutional  effects  of 
arsenic  -poisoning,  or  from  mercurial  stomatitis. 

Treatment. — Treatment  consists  in  providing  free  drainage  by 
incision  of  the  soft  parts  and  involucrum,  when  the  latter  is  present. 
Great  conservatism  should  be  exercised  in  extraction  of  sequestra. 
It  is  best  to  wait  until  they  are  freely  movable  by  probes  introduced 
through  neighboring  cloacae,  and  until  the  involucrum  has  developed 
sufficiently   to  maintain  the  form  of  the  jaw.     Though  the  teeth 


SURGERY  OF  THE  JAWS 


709 


usually  are  lost,  the  ultimate  outcome  as  regards  function  usually 
is  satisfactory. 

Ankylosis  of  the  Temporo-maxillary  Joint  may  be  unilateral  or 
bilateral,  but  even  unilateral  involvement  renders  the  jaw  immovable. 
The  condition  may  result  from  various  forms  of  arthritis  or  from 
fracture  of  the  condyle;  or  false  ankylosis  may  occur  from  peri- 
articular contractures,  due  to  cicatrices  from  burns,  etc.  If  the 
ankylosis  occurs  before  full  development  of  the  mandible,  retrog- 
nathism,  or  micrognathy  is  the  result  (Fig.  784),  from  loss  of 
function.  In  unilateral  ankylosis  the  affected  side  of  the  mandible 
seems  smaller  than  the  sound  side,  but  stands  out  normally  from  the 
neck,  whereas  the  healthy  side  appears  flattened;  the  chin  usually  is 
deviated  toward  the  affected  side  (Kirstein,  1910). 


Fig.  784. — Retrognathism  from  ankylosis  of  jaw,  following  arthritis  in  infancy. 
Now  fifteen  years  old.     Dr.  Gill's  patient.     Orthopaedic  Hospital. 


Treatment. — Some  form  of  arthroplasty  (p.  252)  is  necessary  to  re- 
store motion.  The  joint  is  best  exposed  by  turning  down  from  above 
a  skin-flap  with  temporary  resection  of  the  zygoma  (Lilienthal, 
1911).  The  condyle  of  the  mandible  is  then  excised,  and  a  flap  turned  in 
from  the  temporal  muscle  or  masseter.  By  turning  down  the  zygoma, 
with  attached  masseter  muscle,  any  damage  to  the  facial  nerve, 
parotid  gland,  and  duct,  is  avoided.  The  periosteal  insertion  of  the 
external  pterygoid  muscle  should  be  preserved.  The  older  operations 
of  resection  of  a  wedge  from  the  body  of  the  mandible  in  front  of  the 
angle  seldom  succeeded  in  restoring  permanent  motion.  For  false 
ankylosis  from  cicatricial  contractures  a  plastic  operation  is  necessary. 
Murphy  (1913)  used  a  flap  of  mucous  membrane  from  the  hard  palate. 
The  mandible  may  be  lengthened  by  osteoplastic  operation  on  both 
sides,  dividing  the  body  in  sigmoid  fashion  and  sliding  the  lower 
segment  forward;  but  if  the  ankylosis  is  overcome  before  adult  life, 
some  development  of  the  mandible  may  occur  before  full  growth  of  the 
bodv  is  attained. 


710 


SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 


Facial  Hemiatrophy  is  a  very  rare  condition  of  obscure  origin,  but 
one  whose  existence  should  be  known  to  the  surgeon,  for  diagnostic 
purposes  (Fig.  785).    The  atrophy  affects  bones  as  well  as  soft  parts. 

It  may  be  associated  with  neuritis 
of  the  trigeminal  nerve,  but  usually 
is  not  painful.  Neurologists  treat 
it  by  electric  currents  and  general 
hygienic  measures. 

Tumors  of  the  Jaw. — These  may 
arise  from  the  alveolar  border  or 
from  the  body  of  the  bone. 

Tumors  of  the  Alveolar  Border. 
— There  are  three  of  these  alveolar 
growths  of  considerable  frequency: 
Epulis,  Ossifying  Periosteitis,  and 
Carcinoma. 

1.  Epulis. — Epulis,  a  connective 
tissue  tumor,  is  the  most  frequent 
growth  of  the  alveolus.  Pathologic- 
ally it  is  either  (a)  a  fibroma  or  an 
angeio-fibroma,  or  (b)  a  tumor  con- 
taining giant  cells,  resembling  a 
myeloma  or  myeloid  sarcoma.  This 
appears  to  be  the  only  region  in 
the  body  where  giant  cells  spring 
from  periosteum.  EpuKs  seems 
to  be  more  nearly  related  to  in- 
flammatory processes  than  to  true  neoplasms.  The  giant-celled  form 
often  arises  above  an  old  root  or  beside  a  decayed  tooth,  and  is  red- 
dish brown  in  color;  but  the  fibrous  form  may  occur  where  the  teeth 
appear  normal,  and  is  whiter  in  color.  Epulis  is  painless,  but  in 
spite  of  this  fact  often  has  been  mistaken  for  an  alveolar  abscess.  It 
occurs  in  children  or  young  adults,  is  soft  and  elastic,  but  does  not 
fluctuate.  Ulceration  may  occur  eventually,  but  is  very  long  delayed. 
Treatment. — Treatment  consists  in  local  extirpation  by  knife  and 
gouge  forceps,  through  healthy  tissues.  The  raw  surface  left  should  be 
seared  with  the  actual  cautery.  Recurrence  may  take  place  if  the 
surgeon  is  too  conservative.  Yet  even  after  repeated  recurrence  no 
metastasis  occurs.  It  never  is  necessary  to  excise  the  whole  thick- 
ness of  the  bone;  removal  of  the  portion  of  the  alveolus  affected  is 
sufficient. 

2.  Ossifying  Periosteitis  forms  a  diffuse  bony  enlargement  of  the 
alveolus.  It  may  be  due  to  chronic  infection  (as  pyorrhea  alveolaris). 
Subperiosteal  resection  may  be  done,  without  fear  of  recurrence. 

3.  Carcinoma. — Carcinoma  is  commoner  on  the  upper  (Fig.  786)  than 
the  lower  jaw  (Fig.  787).  It  is  sufficiently  distinguished  from  epulis 
by  its  occurrence  only  in  older  patients,  by  its  early  ulceration,  the 
marked  induration   of  the  borders  of  the  ulcer,  and  the  ultimate 


Fig.  785. — Left  facial  hemiatrophy. 
Male  twenty-six  years  old.  Duration 
ten  months.  No  injury,  but  he  was  a 
"boxer"  and  deformity  was  mistaken 
for  that  due  to  impacted  and  united 
fracture  of  ascending  ramus  of  lower 
jaw.  Notice  over-lapping  of  teeth. 
Episcopal  Hospital. 


SURGERY  OF  THE  JAWS 


711 


involvement  of  the  lymph  nodes.  Extirpation,  together  with  wide 
excision  of  the  lymphatics  of  the  same  side  as  the  lesion,  is  the  proper 
treatment. 


Fig.  786. — Carcinoma  of  upper  jaw.  Age 
seventy-three  years;  duration  six  months, 
now  inoperable.  Was  struck  on  this  side  of 
mouth  one  year  ago  by  handle  of  "release" 
while  running  engine.    Episcopal  Hospital. 


Fig.  787. — Recurrent  carcinoma  of 
inferior  maxilla.  Partial  excision  of 
mandible  in  September,  1906.  Pho- 
tograph March  1908.  Now  inoperable. 
(Dr.  H.  C.  Deaver's  case.)  Episcopal 
Hospital. 


Tumors  of  the  Body  of  the  Jaw.— Some  of  these  are  benign,  and 
some  are  malignant.  Among  the  former  are  dentigerous  cysts,  espe- 
cially the  adamantinoma.  These  were  discussed  at  p.  112.  Of  the 
malignant  tumors  (sarcomas)  there  are  various  forms.  Until  recently 
the  giant-celled  form  of  epulis,  affecting  the  alveolus,  was  classed  as 
a  sarcoma.  True  sarcoma  may  affect  the  body  of  either  the  upper 
or  lower  jaw.  Usually  it  is  periosteal  in  origin,  and  grows  as  a  firm  or 
even  a  bony  tumor.  It  does  not  present  egg-shell  crackling,  which  is 
common  in  the  admantinoma,  and  occurs  in  older  patients  than  those 
in  whom  dentigerous  cysts  usually  are  seen.  According  to  Bloodgood 
sarcoma  of  the  lower  jaw  in  front  of  the  angle  usually  is  of  a  less  malig- 
nant nature  than  the  forms  which  occur  at  the  angle  and  rapidly  invade 
the  ramus.  The  former  (less  malignant)  growths  are  "mixed  sar- 
comas," that  is,  partly  bony,  fibrous,  or  myxomatous,  and  are  rare 
after  the  age  of  twenty-five  years.  The  more  malignant  varieties, 
which  are  rare  before  the  age  of  twenty-five  years,  are  spindle-  and 
round-celled  sarcomas.  These  latter  quickly  invade  the  soft  parts, 
extending  in  the  upper  jaw  to  the  antrum  (where,  indeed,  they  may 
originate),  to  the  orbit,  and  to  the  temporo-maxillary  fossa;  and  in 
the  lower  jaw  invading  the  pharynx  and  soft  structures  of  the  neck. 
The  differential  diagnosis  is  best  made  from  an  excised  specimen. 


712  SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 

Treatment.  In  the  less  malignant  forms  of  sarcoma,  the  surgeon 
aims  to  remove  the  entire  growth,  with  a  small  margin  of  healthy 
tissue  on  all  sides.  In  the  lower  jaw  this  usually  necessitates  a  resec- 
tion of  the  entire  thickness  of  the  hone,  though  very  occasionally  the 
alveolar  border  may  he  left  as  a  splint  to  maintain  the  form  of  the  bone. 
In  the  upper  jaw  it  usually  is  possible  to  preserve  the  orbital  plate, 
and  often  the  hard  palate  also.  It  is  doubtful  whether  any  operation, 
even  the  most  radical,  is  of  any  use  whatever  in  the  more  malignant 
forms  of  sarcoma. 

Excision  of  the  Superior  Maxilla. — The  typical  operation,  though 
seldom  done  at  present  for  tumors  arising  in  the  maxilla  itself,  some- 
times is  required  as  a  preliminary  to  the 
removal  of  growths  in  the  naso-pharynx. 
Preliminary  ligation  of  the  external  carotid 
artery  is  advisable  if  the  operation  is  for 
exposure  of  such  a  tumor.  The  incision 
shown  in  Fig.  788  enters  the  nostril  and 
outlines  a  flap  which  is  reflected  outward, 
the  knife  being  kept  close  to  the  peri- 
osteum. The  mucous  membrane  of  the 
hard  palate  is  divided  in  the  median  line, 
and  the  attachment  of  the  soft  palate  to 
the  bone  severed  transversely.  The  mu- 
cous membrane  of  the  gingivo-labial  fold 
Fig.  788.— Fergusson's  incision  is  divided  clear  of  the  disease,  and  that  in 
for  excision  of  upper  jaw.         the  floor  of  the  nose  is  divided   in   the 

median  line.  After  extraction  of  the  cen- 
tral incisor  tooth  on  the  involved  side,  the  alveolus  and  palate  are 
divided  by  a  phalangeal  saw  (Fig.  152,  6),  introduced  through  the 
nostril.  The  tissues  of  the  orbit  are  then  displaced  upward,  the  spheno- 
maxillary fissure  is  identified,  and  the  attachment  of  the  maxilla  to 
the  malar  bone  is  divided  with  saw.  Then  the  nasal  process  of  the 
maxilla  is  divided  from  orbital  to  nasal  cavity  by  large  bone-cutting 
forceps,  and  the  bone  is  grasped  in  lion-jawed  forceps  and  pulled  down- 
ward, any  remaining  attachments,  including  the  junction  of  the  ptery- 
goid processes  with  the  maxilla,  being  severed  with  bone-cutting 
forceps  or  chisel.  Hemorrhage  is  then  controlled,  if  necessary  by  the 
actual  cautery.  The  mucosa  of  the  cheek  is  then  sutured  to  that  of  the 
palate,  and  the  skin  wound  closed  with  interrupted  sutures,  after 
.packing  the  cavity  loosely  with  iodoform  gauze,  which  is  made  accessi- 
ble through  the  nostril.  Frequent  syringing  through  the  nostril  or  any 
opening  in  the  roof  of  the  mouth  is  required  during  convalescence. 
Temporary  resection  of  the  superior  maxilla  is  done  by  the  same  skin 
incision,  but  the  flap  is  not  separated  from  the  bone;  this  is  divided  as 
above  described  except  at  its  malar  attachment,  which  is  used  as  a 
hinge,  after  fracture  by  leverage  outward. 

Excision  of  the  Inferior  Medulla. — The  typical  operation  involves 
only  half  the  mandible.     After  clearing  the  submaxillary  and  sub- 


SURGERY  OF  THE  TONSIL  AND  PHARYNX  713 

mental  regions  through  the  usual  incision  (Fig.  775),  the  soft  parts  are 
separated  from  the  outer  surface  of  the  bone,  respecting  the  branches 
of  the  facial  nerve,  but  ligating  the  facial  and  the  lingual  arteries  and 
veins.  Most  of  the  external  surface  of  the  ramus  is  thus  exposed. 
The  skin  incision  is  then  carried  up  through  the  lower  lip,  and  the 
cheek  turned  aside.  The  symphysis  is  then  divided  with  saw  and 
the  structures  of  the  floor  of  the  mouth  cut  with  scissors,  from  before 
backward.  An  incision  is  then  made  along  the  mucous  membrane 
on  each  side  of  the  ascending  ramus  of  the  jaw;  the  bone  is  forcibly 
depressed,  and  the  insertion  of  the  temporal  muscle  into  the  coronoid 
process  is  divided  with  scissors.  The  jaw  is  then  turned  somewhat 
outward,  and  the  pterygoid  muscles  cut  close  to  their  insertions. 
The  lingual  nerve  should  be  preserved  if  possible,  but,  of  course, 
the  inferior  dental  must  be  sacrificed.  The  temporo-maxillary  joint 
may  then  be  opened,  the  few  remaining  attachments  severed,  and  the 
bone  removed.  After  careful  control  of  all  hemorrhage,  the  pterygoids 
are  sutured  to  the  masseter  muscle,  and  the  mucous  membrane  of  the 
cheek  united  to  that  of  the  floor  of  the  mouth.  Finally  the  skin 
wound  is  closed,  with  provision  for  drainage  externally.  Partial 
excision  involves  removal  only  of  the  portion  of  bone  affected,  after 
its  division  in  front  of  and  behind  the  growth. 

Prosthesis  after  Excision  of  the  Inferior  Maxillary  Bone. — If  the 
periosteum  can  be  preserved,  a  shell  of  bone  sufficient  to  prevent  exces- 
sive deformity  may  be  formed  in  time.  While  the  wound  is  healing 
the  remaining  portions  of  the  bone  should  be  held  in  proper  position 
by  stout  silver  wire,  used  as  a  bridge  across  the  gap  left  by  excision 
of  the  diseased  portion.  A  sinus  usually  persists  until  the  wire  is 
removed,  but  by  that  time  the  bone  may  be  sufficiently  firm.  Claude 
Martin,  of  Lyons,  since  1878,  has  employed  after  excision  of  either 
upper  or  lower  jaw,  a  temporary  prosthesis  made  of  hard  rubber,  pre- 
viously constructed  to  fit  into  the  contemplated  defect.  This  pros- 
thesis is  riddled  with  channels,  and  though  it  is  implanted  into  the 
wound  through  the  buccal  aspect  (no  attempt  being  made  to  close 
anything  but  the  skin),  the  wound  and  the  appliance  may  in  almost 
all  cases  be  kept  clean  by  irrigation  through  its  numerous  channels 
until  healing  occurs.  When  healing  is  complete  a  permanent  prosthesis 
is  constructed. 

SURGERY  OF  THE  TONSIL  AND  PHARYNX. 

Peritonsillar  Abscess  or  Quinsy  usually  is  a  sequel  of  parenchy- 
matous amygdalitis.  The  systemic  symptoms  of  sepsis  may  be  marked. 
Locally,  in  addition  to  the  signs  of  the  preceding  tonsillitis,  may  be 
observed  a  diffuse  swelling  of  the  soft  palate  at  the  upper  border  of 
the  tonsil.  At  no  time  is  a  distinct  sense  of  fluctuation  obtainable. 
Early  evacuation  is  the  only  satisfactory  treatment.  Thrust  a  grooved 
director  through  the  most  prominent  part  of  the  swelling  (usually 
through  the  soft  palate),  after  painting  it  with  10  per  cent,  cocain 


714 


SURGERY  OF  THE  FACE,   MOUTH,   AND  NECK 


Fig.  789. — Puncture  of  peritonsillar  abscess 
through  soft  palate. 


(Fig.  789).  The  tract  made  by  the  grooved  director  may  be  enlarged 
by  inserting  the  closed  points  of  a  pair  of  dressing  forceps,  and  with- 
drawing the  instrument  with  the  blades  opened.  The  relief  is  imme- 
diate, and  under  the  use  of  simple  alkaline  mouth  washes  conva- 
lescence  usually  is  established   in   twenty-four   to  thirty-six   hours. 

If  a  peritonsillar  abscess  is 
left  to  burst  of  itself,  it  may 
do  so  during  sleep,  and  has 
caused  death  from  suffoca- 
tion. In  very  young  children 
it  is  better  to  open  it  in  the 
head-low  position. 

Malignant  Tumors  of  the 
Tonsil.  —  Either  carcinoma 
or  sarcoma  may  occur  in  the 
tonsil.  Diagnosis  is  not  easy. 
Any  unilateral  tonsillar  en- 
largement in  an  adult  should 
be  regarded  with  suspicion. 
The  possibility  of  syphilitic 
lesions  of  the  tonsil  (chan- 
cre and  ulcerated  gumma) 
should  be  kept  in  mind,  and 
their  presence  excluded  by  the  history  of  the  case,  the  existence  of 
evidences,  past  or  present,  of  the  disease  elsewhere  in  the  body;  as 
well  as  by  the  use  of  laboratory  and  therapeutic  tests.  In  most  cases 
a  specimen  of  the  growth  should  be  excised  for  microscopic  study. 
In  carcinoma  the  diagnosis  usually  is  easily  made  by  this  means, 
but  in  sarcoma  the  histological  picture  may  not  be  convincing. 

Symptoms. — The  symptoms  are  chiefly  those  of  obstruction,  in 
sarcoma,  with  pain  on  deglutition;  the  lymph  nodes  seldom  become 
enlarged  until  late  in  the  disease,  after  ulceration  has  occurred. 
Local  extension  to  the  palate  and  pharynx  is  much  more  common  in 
carcinoma,  and  in  this  affection  the  submaxillary  and  deep  cervical 
lymph  nodes  are  involved  early,  though  not  palpably  so  for  a  number 
of  weeks. 

Treatment. — If  the  diagnosis  is  made  very  early  in  the  disease, 
by  means  of  microscopic  study,  it  may  be  possible  to  enucleate  the 
tonsil  from  within  the  mouth.  Usually,  however,  and  particularly 
in  the  case  of  carcinoma,  the  growth  should  be  approached  from  the 
outside,  as  in  the  operation  for  excision  of  the  tongue  described  at 
p.  700.  In  lateral  yharyngotomy  the  growth  is  approached  from  the 
submaxillary  region.  It  may  also  be  approached  by  suprahyoid 
yharyngotomy  (Jeremitsch,  1895;  von  Hacker,  1906).  Subhyoid 
pharyngotomy  (Vidal  de  Cassis,  1826;  Sklifosovsky,  1892)  is  a  somewhat 
similar  operation,  but  there  is  more  danger  of  injuring  the  superior 
laryngeal  nerve,  without  compensating  advantages.  When  the  malig- 
nant growth  has  been  excised,  the  severed  cervical  tissues  are  carefully 


SURGERY  OF  THE  AIR  PASSAGES  715 

re-united  by  many  rows  of  buried  sutures,  and  the  wound  is  freely 
drained.  These  pharyngotomies  are  dangerous,  seldom  employed,  and 
difficult  even  for  skilled  operators  with  accurate  anatomical  knowledge. 

If  the  case  is  inoperable,  palliative  measures,  such  as  the  "starva- 
tion" method  of  Dawbarn  (p.  705),  may  be  tried,  with  the  use  of 
radium,  the  .r-ray,  and,  in  the  case  of  sarcoma,  of  Coley's  fluid. 

Tumors  of  the  Naso-pharynx. — These  usually  are  soft  fibromas, 
occur  in  young  adults  from  fifteen  to  twenty -five  years  of  age,  and  in 
many  cases  assume  a  character  which  clinically  is  malignant,  though 
microscopical  examination  rarely  shows  a  typical  sarcoma.  They 
spring  from  the  submucous  tissues  at  the  base  of  the  skull,  and  grow 
into  the  nasal  passages,  invade  the  maxillary  sinus,  the  orbit,  the 
temporal  fossa,  and  may  open  even  the  cranial  cavity.  Occasionally 
they  seem  to  spring  from  the  antrum  and  grow  backward  into  the 
naso-pharynx.  Unless  removed,  death  is  practically  certain  from 
obstruction  to  respiration  and  deglutition.  Moure  and  Canuyt  (1914) 
point  out  that  the  growth  usually  is  attached  by  a  small  pedicle, 
which  often  may  be  exposed  by  partial  resection  of  the  maxilla,  opening 
simultaneously  from  the  front  the  maxillary  antrum  and  the  nasal 
fossse.  The  growth  is  apt  to  recur  after  partial  removal,  and  complete 
extirpation  may  demand  excision  of  the  superior  maxilla  (p.  712)  to 
gain  access  to  the  growth,  even  if  this  bone  is  not  itself  invaded  by  the 
disease.  Preliminary  ligation  of  the  external  carotid  artery  is  advisable, 
and  the  actual  cautery  may  be  required  to  check  the  bleeding  even 
after  this  precaution. 

SURGERY  OF  THE  AIR  PASSAGES. 

Foreign  Bodies. — Foreign  bodies  are  especially  apt  to  enter  the 
larynx,  trachea,  or  bronchial  tubes  in  young  children,  who  thoughtlessly 
place  various  objects  in  the  mouth,  and  by  a  sudden  act  of  inspiration, 
in  laughing  or  coughing,  draw  them  into  the  larynx.  In  anesthetized 
patients,  or  those  in  a  drunken  stupor,  vomited  matters  may  be  simi- 
larly aspirated  into  the  air  passages.  Severe  paroxysms  of  choking 
ensue,  but  very  rarely  does  rapid  death  from  asphyxia  occur.  Apart 
from  asphyxia,  the  chief  danger  is  due  to  secondary  pulmonary  inflam- 
mation. Occasionally  a  foreign  body  is  arrested  in  the  larynx,  but  in 
most  instances  it  passes  down  into  the  trachea,  and  thence  usually 
into  one  or  other  bronchus. 

Symptoms. — Symptoms  depend  on  the  site  of  the  foreign  body,  and 
on  the  time  which  has  elapsed  since  the  accident.  The  first  symptoms, 
or  those  of  obstruction,  seldom  last  very  long.  They  are  succeeded 
by  those  of  irritation,  denoted  by  a  short  croupy  cough,  with  retro- 
sternal pain,  and  later  by  mucous  or  bloody  expectoration;  paroxysms 
of  dyspnea  occur  from  time  to  time  when  the  foreign  body  is  forced 
upward  into  the  larynx.  If  impacted  in  the  larynx,  symptoms  of 
obstruction  persist,  and  there  usually  is  aphonia.  If  impacted  in  a 
bronchus,  or  if  immovably  fixed  at  any  point  by  a  sharp  projection 


716 


SURGERY  OF  THE  FACE,   MOUTH,  AND  NECK 


catching  in  the  mucous  membrane,  the  symptoms  of  irritation  are  not 
very  marked;  and  auscultation  over  the  region  of  the  lung  obstructed 
usually  detects  very  weak  or  absent  respiratory  murmur,  but  no  dulness 
is  found  on  percussion  until  inflammatory  changes  arise.  If  the  for- 
eign body  moves  freely  about  in  respiration,  the  symptoms  of  irritation 
are  very  pronounced,  and  occasionally  the  foreign  body  can  be  heard 
flapping  about. 

Diagnosis. — The  diagnosis  in  small  children  must  be  made  from 
"croup"  or  diphtheria,  and  in  the  absence  of  a  clear  history,  and  where 
there  is  no  evidence  of  diphtheritic  membrane  in  the  pharynx,  this  is 
difficult,  without  laryngoscopic  examination.  When  a  foreign  body  is 
present  dyspnea  occurs  particularly  in  expiration,  while  in  laryngeal 
obstruction  from  other  causes,  inspiratory  dyspnea  is  found.  More- 
over, if  the  foreign  body  is  sufficiently  dense  (a  pebble  or  some  metallic 
toy),  its  presence  will  be  revealed  by  the  x-ray.  In  the  case  of  foreign 
bodies  impacted  in  the  pharynx  or  esophagus  there  rarely  is  so  much 
dyspnea,  and  swallowing  will  be  difficult  or  impossible.  A  foreign 
body  in  the  pharynx  usually  can  be  reached  by  a  finger  introduced 
into  the  mouth. 

Treatment. — 1.  In  emergencies,  any  physician  may  open  the  trachea 
and  extract  the  foreign  body  if  it  can  be  found.  If  impacted  in  the 
larynx,  high  tracheotomy  or  crico-thyrotomy  should  be  preferred. 
In  other  cases  low  tracheotomy  is  better.  Even  if  the  foreign  body  is 
not  found  it  is  more  apt  to  be  discharged  spontaneously  through  a 
tracheotomy  wound  than  by  the  natural  passages. 


Fig.  790. — Upper  bronchoscopy. 

2.  When  there  is  no  emergency,  the  services  of  a  skilled  laryngologist 
should  be  procured.  He  may  be  able,  by  means  of  a  bronchoscope 
introduced  through  the  mouth  (upper  bronchoscopy)  to  see  and  extract 
the  foreign  body  (Fig.  790).  If  it  is  situated  too  low  to  be  reached 
successfully  from  above,  the  same  method  may  be  employed,  the 
instrument  being  introduced  through  a  "low  tracheotomy"  wound 
(p.  719),  the  procedure  then  being  known  as  lower  bronchoscopy.  This 
is  very  rarely  employed.  Bronchoscopy  was  introduced  by  Killian  in 
1897,  and  has  been  highly  developed  by  Guisez  in  France,  and  by 
Chevalier  Jackson  in  this  country. 


SURGERY  OF  THE  AIR  PASSAGES  717 

Fracture  of  the  Larynx  is  rare.  The  thyroid  is  the  cartilage  most 
often  involved.  Michel  (1910)  studied  40  cases  recently  reported. 
Among  these  there  were  17  deaths.  Seven  of  these  patients  died 
suddenly,  without  operation,  at  periods  varying  from  a  few  hours  to 
six  days  after  the  accident.  The  mortality  in  non-operative  cases  is 
42  per  cent.  In  very  severe  injuries,  where  the  fracture  is  compound 
internally  (hemoptysis,  threatening  asphyxia  from  edema  of  the  glottis) 
tracheotomy  should  be  done,  and  the  deformity  corrected.  In  very 
mild  cases,  no  operation  is  required,  it  being  sufficient  to  apply  a 
light  immobilizing  dressing.  In  intermediate  cases,  especially  if  there 
is  any  emphysema,  tracheotomy  should  be  done  as  a  precautionary 
measure,  since  experience  shows  that  in  such  cases  sudden  death  is  apt 
to  occur  from  edema  of  the  glottis. 

Edema  of  the  Glottis. — Above  the  true  vocal  cords  there  is  abun- 
dance of  loose  areolar  submucous  tissue,  prone  to  edema  from  trauma 
or  infection.  Below  the  vocal  cords  the  mucosa  is  tightly  applied  to 
the  cartilage.  The  symptoms  of  edema  of  the  glottis  usually  develop 
very  suddenly  and  often  quite  unexpectedly.  They  are  those  of 
asphyxia.  Treatment,  which  must  be  immediate,  consists  in  crico- 
thyrotomy  or  high  tracheotomy  (p.  719). 

Tumors  of  the  Larynx. — These  belong  rather  to  the  province  of  the 
laryngologist  than  to  that  of  the  general  surgeon,  except  when  external 
operations  are  required.  In  any  such  case  it  is  well  for  surgeon  and 
laryngologist  to  act  in  consultation. 

The  most  frequent  benign  tumor  is  the  papilloma.  It  may  occur  in 
patients  of  any  age,  but  is  most  frequent  in  young  adults.  Early 
symptoms  of  hoarseness,  with  recurrent  attacks  of  laryngitis,  finally 
will  be  followed  by  those  of  respiratory  obstruction.  The  diagnosis 
is  confirmed  by  inspection  of  the  larynx  through  a  mirror  introduced 
above  its  superior  aperture  (laryngoscopy).  Benign  growths  usually 
are  pedunculated;  ulceration  or  bleeding  points  to  malignancy. 
Pedunculated  growths  usually  may  be  removed  by  intra-laryngeal 
methods,  in  the  hands  of  a  specialist.  Papilloma  is  very  apt  to  recur, 
but  other  forms  of  benign  tumors  rarely  return.  The  performance  of 
tracheotomy,  with  the  use  of  a  tracheal  tube  sometimes  has  served 
to  prevent  recurrence,  by  putting  the  larynx  completely  at  rest. 

Carcinoma. — Carcinoma  is  the  most  frequent  malignant  tumor.  It 
is  said  to  be  rare  as  a  sequel  of  papilloma.  Sarcoma  is  very  rare. 
In  many  cases  the  growth  involves  the  larynx  secondarily,  having 
originated  in  the  tongue,  pharynx,  or  esophagus;  this  form  is  described 
as  extrinsic  carcinoma  of  the  larynx,  as  distinguished  from  intrinsic 
carcinoma,  arising  primarily  within  the  larynx.  The  symptoms  are 
the  same  as  in  benign  growths,  but  the  patients  are  older  (it  is  rare 
before  fifty  years),  there  is  more  pain,  and  sometimes  there  is  sponta- 
neous bleeding.  The  diagnosis  is  made  by  laryngoscopy,  and  if  neces- 
sary by  microscopical  examination  of  an  excised  portion  of  the  growth. 
The  disease- usually  is  more  extensive  than  it  seems.  Tuberculosis 
and  syphilis  have  to  be  considered,  but  usually  may  be  excluded  by 


718 


SURGERY  OF  THE  FACE,   MOUTH,   AND  NECK 


the  history  of  the  case,  by  clinical  examination,  and  by  laboratory 
tests.  The  prognosis  of  carcinoma  of  the  larynx  is  bad.  Without 
operation  death  usually  occurs  within  three  years,  and  it  is  a  very 
painful  death.  Treatment  should  be  radical  whenever  possible,  and  it 
is  best  accomplished  by  external  operation. 


OPERATIONS  ON  THE  AIR  PASSAGES. 

Intubation  of  the  Larynx. — This  operation,  introduced  by  O'Dwyer 
in  1885,  consists  in  the  introduction  into  the  larynx,  by  special  instru- 
ments passed  through  the  mouth,  of  a  hollow  tube  which  is  allowed 
to  remain,  suspended  from  the  false  vocal  cords,  until  the  symptoms 
of  laryngeal  stenosis,  for  which  the  operation  was  done,  have  sub- 
sided. It  is  employed  almost  solely  for  laryngeal  obstruction  resulting 
from  diphtheria.  The  armamentarium  comprises  a  set  of  hollow  hard 
rubber  tubes  of  various  sizes  suitable  for  any  age  up  to  twelve  years. 
The  approximate  size  is  determined  beforehand  by  means  of  a  scale. 
Each  tube  is  provided  with  a  hole  at  its  upper  end  through  which  a 
long  thread  is  passed;  the  thread  is  left  hanging  out  of  the  patient's 
mouth  and  enables  the  tube  to  be  quickly  withdrawn  if  necessary. 
The  tube  is  then  fitted  over  the  obturator,  which  is  screwed  securely 
to  the  introducer.    A  gag  is  placed  in  the  left  side  of  the  mouth,  and 

the  child  (not  anesthetized)  is 
held  upright  in  the  nurse's 
arms,  with  head  steadied  and 
slightly  extended.  The  surgeon 
then  introduces  his  left  fore- 
finger and  draws  the  tip  of  the 
epiglottis  forward.  The  intro- 
ducer is  then  passed  backward 
by  the  right  hand  and  the  tip 
of  the  tube  is  guided  into  the 
larynx  by  the  finger  of  the  left 
hand  (Fig.  791).  The  tube  is 
then  quickly  pushed  off  the 
obturator  by  means  of  the  slid- 
ing shaft  on  the  introducer, 
and  the  latter  with  the  obtur- 
ator still  attached  is  with- 
drawn. The  thread  fastened 
to  the  tube  is  left  hanging  out 
of  the  mouth,  until  it  is  certain  that  the  tube  will  be  well  borne. 
If  the  tube  has  been  passed  into  the  esophagus  by  mistake,  it 
should  be  withdrawn  at  once,  cleansed,  and  properly  reinserted.  If 
dyspnea  is  not  relieved  when  the  tube  is  in  the  larynx,  a  larger  tube 
should  be  inserted.  If  the  tube  is  well  borne,  the  thread  may  be 
removed  after  a  few  hours.  When  necessary  the  tube  may  then  be 
removed  by  the  extractor,  reversing  the  steps  employed  in  its  intro- 
duction. 


Fig.  791. — Intubation  of  larynx. 


OPERATIONS  ON  THE  AIR  PASSAGES  719 

The  mortality  due  to  the  operation  itself  is  very  inconsiderable, 
but  death  may  occur  in  spite  of  the  operation.  Intubation  should  be 
preferred  to  tracheotomy  in  all  cases  in  which  it  is  applicable.  When 
it  fails  to  relieve  the  obstruction,  tracheotomy  may  still  be  done, 
and  a  tube  inserted  below  the  obstruction. 

In  cutting  operations  upon  the  air  passages  the  patient  should  be 
in  the  "hanging  head  position"  (Fig.  756);  this  not  only  renders  the 
parts  more  accessible,  but  avoids  so  far  as  possible  aspiration  of  blood 
or  gastric  contents.  In  cases  where  partial  asphyxia  is  present,  no 
anesthetic  is  required;  in  others  local  anesthesia  usually  is  sufficient 
except  where  the  soft  parts  have  been  invaded  by  malignant  disease. 
Shortly  before  extensive  operations  (thyrotomy,  laryngectomy)  a 
hypodermic  injection  should  be  given  of  morphin  and  atropin  to 
diminish  secretion  and  paralyze  inhibitory  impulses. 

Crico-thyrotomy,  in  which  an  incision  is  made  in  the  cricothyroid 
membrane,  occasionally  is  done  for  acute  laryngeal  obstruction  in 
adults.  The  wind-pipe  is  here  most  accessible,  and  in  emergencies 
there  is  no  other  method  by  which  it  may  be  so  quickly  opened.  But 
there  is  some  danger  of  injuring  the  recurrent  laryngeal  nerve,  and  as 
the  larynx  itself  is  opened  it  is  not  considered  a  proper  operation  for 
diphtheritic  obstruction,  as  the  false  membrane  may  extend  below  the 
seat  of  operation.  But  in  cases  of  edema  of  the  glottis  this  objection 
does  not  apply.  No  anesthetic  is  required.  The  surgeon  fixes  the 
cricoid  cartilage  between  the  thumb  and  finger  of  his  left  hand,  and 
makes  a  small  transverse  incision  in  the  skin  over  the  cricothyroid 
space.  The  sternohyoid  muscles  are  then  separated,  and  the  blade 
of  the  knife  is  entered  transversely  through  the  cricothyroid  mem- 
brane. If  the  cricothyroid  artery  is  wounded,  it  should  be  clamped 
and  tied  before  opening  the  larynx.  Occasionally  it  is  of  large  size. 
A  tracheotomy  tube  is  then  introduced,  and  the  after-treatment  con- 
ducted as  in  a  case  of  tracheotomy. 

Tracheotomy. — The  trachea  may  be  opened  either  above  {high 
tracheotomy)  or  below  the  isthmus  of  the  thyroid  gland  (low  trache- 
otomy) .  Usually  two  or  three  rings  are  accessible  above,  and  as  many 
below  the  isthmus.  The  high  operation  usually  is  to  be  preferred  if 
the  indication  is  laryngeal  obstruction,  but,  as  already  mentioned,  low 
tracheotomy  is  preferable  for  the  removal  of  a  foreign  body  in  the 
bronchi.  The  higher  the  trachea  is  approached,  the  nearer  does  it 
lie  to  the  surface  of  the  neck;  and  in  the  suprasternal  region  access  to 
it  is  obscured  by  numerous  veins,  which  are  markedly  engorged  in 
cases  of  respiratory  obstruction,  and  render  the  operation  much  more 
difficult  (Fig.  792).  No  anesthetic  is  required.  Partial  asphyxiation 
renders  the  patient  almost  insensible  to  pain,  and  the  first  incision  cuts 
all  the  sensory  nerves.  Most  surgeons  still  employ  a  longitudinal  skin 
incision,  but  I  believe  with  O.  Franck  a  transverse  one  is  better,  as 
it  is  less  liable  to  subsequent  infection,  gives  better  exposure  and 
leaves  an  inconspicuous  scar.  If  the  skin  is  pinched  up  in  the 
fingers,  the  anterior  jugular  veins  do  not  come  with  it,  and  there  is 
almost  no  bleeding.    The  interspace  between  the  sternohyoid  mus- 


720 


SURGERY  OF  THE  FACE,   MOUTH,  AND  NECK 


cles  is  identified,  and  these  as  well  as  the  underlying  sternothyroids 
are  separated,  exposing  the  trachea.  This  is  then  fixed  in  the  wound 
by  a  sharp  tenaculum.  Unless  this  precaution  is  taken  it  may  be 
very  difficult  to  cut  the  cartilages,  especially  in  an  adult,  as  the 
knife  is  apt  to  push  the  trachea  deeper  into  the  neck  or  to  one  side. 
Two  or  possibly  three  cartilages  are  then  divided,  in  the  long  axis 
of  the  trachea,  strictly  in  the  median  line.  Or  the  trachea  may  be 
opened  transversely,  between  two  rings;  it  will  gape,  owing  to  the 
hyperextension  of  the  neck.  In  this  way  the  operation  may  be  com- 
pleted with  no  other  instrument  than  the  knife.  The  operator  should 
take  care,  especially  in  cases  of  diphtheria,  that  the  violent  paroxysms 
of  coughing,  which  follow  opening  the  trachea,  do  not  spatter  his  face 
with  false  membrane.  Any  membrane  presenting  in  the  wound  should 
be  carefully  withdrawn.    A  tracheotomy  tube  (Fig.  793)  is  then  inserted, 

and  fastened  in  place  by  tapes  tied 
behind  the  patient's  neck.  This 
tube  is  provided  with  an  inner  can- 
nula which  is  removed  frequently 
and  cleansed,  without  disturbing 
the  outer  tube.  As  long  as  the  tube 
remains  in  place,  the  patient  should 
be  kept  in  a  moist  warm  atmos- 
phere; this  is  best  secured  by  em- 
ploying a  croup  tent,  and  by  the 
use  of  a  kettle  of  hot  water,  on  the 
surface  of  which  is  floated  a  small 
quantity  of  compound  tincture  of 
benzoin.  It  is  an  advantage  to  have 
the  outer  tracheotomy  tube  con- 
structed with  a  window  on  its  con- 
vex surface,  so  that  wdien  the  inner 


Fig.  792. — Sagittal  section  of  neck 
showing  anatomical  landmarks  involved 
in  operations  on  the  larynx  and  trachea. 


Fig.  793.— Tracheotomy  tube. 


tube  is  withdrawn,  tests  can  be  made  from  day  to  day  of  the  possibility 
of  laryngeal  respiration.  In  emergencies,  where  a  tracheotomy  tube  is 
not  available,  one  may  be  constructed  out  of  a  soft  catheter  or  rubber 
drainage  tube.  It  rarely  is  possible  to  remove  the  tube  permanently 
before  the  third  or  fourth  day.  In  cases  of  stenosis  from  cicatrix  or 
neoplasm  it  may  be  necessary  to  wear  a  tracheal  cannula  permanently. 
In  these  cases  a  tube  with  a  ball  valve,  permitting  inspiration  but 
preventing  expiration  through  the  tube,  may  enable  the  patient  to 
employ  his  larynx  in  speaking. 


OPERATIONS  ON  THE  AIR  PASSAGES  721 

Thyrotomy  or  Laryngo-fissure  consists  in  splitting  the  thyroid  car- 
tilage in  the  mid-line,  turning  aside  the  halves,  and  exposing  the 
interior  of  the  larynx.  It  is  used  to  remove  sessile  benign  growths, 
and  as  an  exploratory  operation  in  cases  not  certainly  malignant. 
When  malignancy  exists  the  exploration  should  be  followed  imme- 
diately by  laryngectomy. 

Laryngectomy  may  be  partial  {Hemilaryngectomy)  or  complete  (Extir- 
pation of  the  Larynx).  In  the  latter  operation  Hartley,  of  New  York, 
adopted  (1908)  a  cross-bow  incision,  analogous  to  that  used  in  opera- 
tions on  the  cerebullum.  The  transverse  incision  passes  just  below 
the  level  of  the  hyoid  bone,  and  the  longitudinal  extends  far  enough 
downward  to  expose  the  isthmus  of  the  thyroid  gland.  The  platysma, 
sternohyoid  and  omohyoid  muscles  are  turned  down  in  the  triangular 
flaps.  All  superficial  veins  and  both  superior  thyroid  arteries  are 
ligated,  the  latter  close  to  their  origin;  and  the  superior  laryngeal 
nerves  are  cut.  The  trachea  then  is  cut  away  from  the  cricoid,  is  turned 
forward,  and  is  sutured  end-on  into  the  lower  angle  of  the  incision. 
Division  of  the  thyroid  isthmus  and  free  separation  of  the  trachea  from 
the  esophagus  may  be  necessary.  A  tracheotomy  tube  is  then  intro- 
duced, and  the  anesthetic  subsequently  administered  by  this  route. 
The  sternothyroid  muscles  are  then  divided  below  the  larynx.  The 
pre-laryngeal  and  lateral  laryngeal  lymph  nodes  are  then  raised, 
together  with  the  larynx  and  attached  sternothyroid  muscles,  and  the 
pharynx  is  incised  transversely  behind  the  larynx,  and  the  larynx, 
including  the  epiglottis,  is  removed.  All  bleeding  having  been  con- 
trolled, the  pharynx  is  completely  closed  by  sutures  (over  a  stomach 
tube,  passed  through  the  nose,  and  used  as  a  guide);1  the  musculo- 
cutaneous flaps  are  replaced  and  sutured,  and  the  wound  is  drained 
from  one  or  both  lateral  angles.  After-treatment  is  conducted  as  in 
cases  of  tracheotomy.  The  patient  should  lie  in  the  head-low  position, 
and  should  not  swallow  anything  for  three  days.  Until  then  he  may 
be  fed  liquids  through  the  tube  passed  by  the  nose  into  the  esophagus 
at  the  time  of  operation.  Crile  (1913)  points  out  that  the  chance 
of  infection  may  be  lessened  by  a  preliminary  operation  in  which  the 
suprasternal  space  is  widely  opened  on  both  sides  of  the  trachea  and  is 
packed  with  gauze.  After  several  days  when  the  wound  is  covered  with 
firm  granulations,  the  surgeon  proceeds  to  extirpation  of  the  larynx. 

The  mortality  of  the  operation  is  about  20  per  cent.  Nearly  50 
per  cent,  of  those  who  recover  remain  free  of  recurrence  for  one  year 
or  longer.  About  20  per  cent,  of  those  who  recover  are  permanently 
cured.  Recurrence  usually  takes  place,  if  at  all,  within  one  year. 
If  the  deep  cervical  lymphatics  are  involved,  no  radical  operation  is  of 
any  use. 

Hemilaryngectomy  is  done  by  turning  down  a  triangular  flap  on  one 
side  only.  A  tube  is  inserted  in  the  trachea  well  below  the  cricoid, 
and  after  preliminary  laryngo-fissure,  the  diseased  half  of  the  thyroid 
cartilage  is  removed,  with  its  related  lymph  nodes. 

1  This  tube  should  be  allowed  to  remain. 
46 


722 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


SURGERY  OF  THE  NECK. 

Wounds. — These  may  be  incised,  lacerated,  gunshot,  or  stab  wounds. 
The  chief  immediate  danger  is  hemorrhage  or  edema  of  the  glottis. 
Injuries  of  nerves,  if  undetected  and  not  repaired,  may  lead  to  lasting 
disability.  In  suicidal  cut-throat,  the  patient  often  loses  his  courage 
when  blood  begins  to  flow,  and  the  damage  may  not  be  nearly  so  great 
as  appears  at  first  sight.  If  the  trachea,  larynx,  or  pharynx  are 
wounded,  it  frequently  is  safer  to  insert  a  tracheotomy  tube  at  once, 
to  prevent  asphyxia  should  edema  of  the  glottis  occur.  Usually  no 
anesthetic  is  necessary.  Hemorrhage  should  be  controlled  by  expos- 
ing, clamping,  and  ligating  the  bleeding  points.    Venous  bleeding  may 

cease  after  respiratory  obstruction 
has  been  relieved  by  tracheotomy. 
The  superior  laryngeal  and  the 
hypoglossal  nerves  are  those  most 
frequently  severed  in  suicidal  at- 
tempts. No  prolonged  attempts 
should  be  made  to  repair  the  nerve 
injury  unless  the  patient's  condi- 
tion is  favorable.  A  lodged  bullet 
need  not  be  removed  unless  very 
easily  accessible.  Severed  muscles 
should  be  sutured.  The  wound 
should  be  drained  freely,  as  it  is 
in  a  region  very  prone  to  infec- 
tion. 

Woody  or  Ligneous  Phlegmon 
of  the  Neck  (Reclus,  1893).— This 
is  a  slow  and  indolent  inflamma- 
tion, probably  due  to  attenuated 
bacterial  infection,  the  portal  of 
entrance  of  the  infection  being  un- 
certain. The  inflammatory  pro- 
cess is  said  usually  to  begin  below 
the  jaw  in  the  submaxillary  or 
submental  region,  and  extends  to 
the  clavicle,  usually  on  one  side 
only.  It  converts  the  normally 
supple  neck  into  a  dense  board- 
like structure,  neither  painful  nor 
tender,  and  not  attended  by 
noticeable  constitutional  reac- 
tion. There  may  be  an  erythematous  blush  in  the  skin,  and  pos- 
sibly some  pitting  on  very  firm  pressure,  but  there  is  no  evidence 
of  suppuration.  The  affection,  which  seems  to  be  a  cellulitis  or  possibly 
a  myositis  of  the  platysma,  begins  insiduously  and  may  last  for  weeks 
before  medical  attention  is  sought  (Fig.  794). 


Fig.  794. — Woody  or  ligneous  phlegmon 
of  neck.  Struck  by  steel  two  months  ago. 
Slow,  painless  onset  of  induration,  which 
extends  from  mandible  nearly  to  clavicle, 
and  from  larynx  to  anterior  border  of 
trapezius.  Skin  red,  slight  edema,  and 
pitting  on  pressure.  No  tenderness. 
Poulticed  for  three  days,  then  incised. 
Rapid  recovery.     Episcopal  Hospital. 


SURGERY  OF  THE  NECK 


723 


Treatment. — The  board-like  area  should  be  incised  in  several  places, 
and  the  neck  should  be  poulticed.  After  suppuration  is  established, 
the  indurated  tissues  quickly  soften,  and  recovery  usually  is  unevent- 
ful. This  disease  must  not  be  confused  with  actinomycosis;  the  chief 
point  of  resemblance  is  the  board-like  induration. 

Lymphadenitis. — Inflammation  of  the  lymph  nodes  probably  occurs 
oftener  in  the  neck  than  in  any  other  portion  of  the  body.  The 
cavities  of  the  nose,  mouth,  and  pharynx  constantly  breed  hordes 
of  microbes,  and  whenever  the  virulence  of  these  is  increased,  or  the 
resistance  of  the  patient  lowered,  they  or  their  toxins  are  absorbed, 
largely  through  carious  teeth  or  the  tonsils,  and  secondary  enlarge- 
ment of  the  cervical  lymph  nodes  follows.  The  scalp  also  is  a  very 
prolific  source  of  infection  for  the  cervical  lymph  nodes.  Every  year 
I  see  a  number  of  patients  with  cervical  adenitis  due  to  the  infection 
instituted  by  head  lice. 

It  is  of  the  utmost  importance  not  to  regard  the  lymphadenitis  as 
the  main  feature  of  the  disease.  The  focus  of  infection  always  should 
be  looked  for,  and  usually  can  be  found  if  the  examination  is  thorough. 
If  it  is  found  and  properly  cared  for,  the  lymphadenitis  may  subside 
spontaneously.  Examine  the  scalp,  ear,  teeth,  lips,  tonsils,  nose,  and 
naso-pharynx,  and  do  not  be 
satisfied  until  some  source  of 
infection  has  been  discovered. 
The  anatomical  connections  of 
the  various  groups  of  cervical 
lymph  nodes  should  be  re- 
membered. Around  the  upper 
part  of  the  neck,  as  a  collar, 
are  arranged,  from  before 
backward,  the  submental,  sub- 
maxillary, subparotid,  post-auri- 
cular and  occipital  lymph  nodes, 
draining  corresponding  areas  of 
the  face  and  head.  The  sub- 
maxillary nodes  receive  the 
drainage  from  all  of  the  other 
groups  mentioned  except  the 
occipital,  and  sometimes  the 
submental ;  and  all  these  groups 
directly,  or  indirectly  through 
the  submaxillary,  drain  into  the 
upper  portion  of  the  deep  cer- 
vical lymph  nodes,  which  form  a  chain  along  the  internal  jugular  vein 
from  mastoid  nearly  to  clavicle.  These  deep  cervical  lymph  nodes 
sometimes  are  infected  directly  from  the  primary  focus  of  the  teeth, 
tonsils,  scalp,  etc.,  without  implication  of  the  intermediary  group, 
but  in  most  cases  the  latter  is  infected  first.  The  deep  cervical 
lymph  nodes  are  also  connected  with  the  supraclavicular  lymph  nodes, 


Fig.  795. — -Tuberculous  cervical  and  axillary 
adenitis,  in  a  girl  of  fifteen  years;  duration 
nearly  one  year.  Has  had  two  operations  on 
neck,  both  probably  incomplete;  last,  one  year 
ago.    Episcopal  Hospital. 


724 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


which  drain  the  surfaces  of  the  upper  arm  and  axilla,  and  sometimes 
the  occipital  portion  of  the  scalp  and  the  mammary  gland.  These 
supraclavicular  lymph  nodes  may  be  infected  through  the  deep  cervical 
lymph  nodes,  or  may  in  turn  infect  them.  The  deep  cervical  and 
supraclavicular  nodes  are  themselves  drained  into  the  subclavian  vein 
at  its  junction  with  the  internal  jugular.  The  deep  lymph  nodes 
of  the  neck  lie  beneath  the  sternomastoid  muscle,  and  upon  the  fascia 
which  covers  the  prevertebral  muscles  (scaleni,  levator  anguli  scapulae, 
etc.) ;  their  efferent  vessels  do  not  pass  into  the  mediastinal  nodes, 
but  occasionally  they  receive  afferent  lymphatics  from  this  source. 
Occasionally  the  axillary  lymph  nodes  become  involved  by  infections 
travelling  down  the  neck  and  through  the  supraclavicular  nodes 
(Fig.  795). 

Acute  Lymphadenitis. — The  affected  nodes  are  swollen,  tender,  palpa- 
ble, and  sometimes  visible  as  a  diffuse  swelling  (Fig.  796) .  The  more 
acute  the  process  the  less  distinctly  can  the  individual  node  be  out- 
lined, and  in  many  cases  the  affection  is  so  acute  that  suppuration 
has  occurred  before  the  surgeon  is  consulted.  In  the  earlier  stages, 
attention  to  the  focus  of  infection, 
and  application  of  ichthyol,  bella- 
donna and  mercury,  or  compound 
iodin  ointment  to  the  side  of  the 
neck  affected  usually  cause  sub- 
sidence of  acute  symptoms,  and 
the  nodes  cease  to  be  palpable. 


^■**    *          %2 

*  1 

I 

s\ 

Fig.  796. — Acute  submental  lymph- 
adenitis.    Children's  Hospital. 


Fig.  797. — Submaxillary  abscess  from 
acute  lymphadenitis  (not  tuberculous), 
due  to  carious  teeth.  Age  eleven  years. 
Two  months  later  other  abscesses  formed, 
were  incised  and  curetted.  One  year 
later,  formal  operation  for  tuberculous 
lymph  nodes,  evidently  secondary  to 
previous  inflammation.  (See  Fig.  36.) 
Episcopal  Hospital. 


Abscess  from  cervical  lymphadenitis  (Fig.  797)  requires  the  same 
treatment  as  an  abscess  elsewhere ;  but  as  in  many  cases  the  abscess  is 
quite  deeply  seated,  it  often  is  best  to  open  it  by  Hilton's  Method;  a 
small  superficial  incision  is  made  in  the  skin,  under  local  anesthesia  if 
necessary,  and  then  a  grooved  director  is  cautiously  insinuated  through 


SURGERY  OF  THE  NECK 


725 


the  intervening  structures  until  pus  begins  to  flow;  a  pair  of  dressing 
forceps  is  then  passed  along  the  grooved  director,  with  its  blades 
closed;  when  it  has  entered  the  abscess  cavity  the  blades  are  opened, 
and  the  forceps  is  withdrawn,  thus  dilating  the  tract  previously  made. 
In  this  way  there  is  no  danger  of  injuring  important  bloodvessels  or 
nerves. 

Chronic  Lymphadenitis. — Chronic  lymphadenitis  usually  follows  re- 
peated acute  attacks,  the  nodes  retaining  some  inflammatory  hyper- 
plasia after  each  new  infection.  In  the  vast  majority  of  cases,  under 
these  circumstances,  the  nodes  become  secondarily  infected  with 
tubercle  bacilli.  It  is  possible,  of  course,  that  the  primary  infection 
may  have  been  tuberculous,  since  even  in  cases  which  clinically  are 
thought  not  to  be  tuberculous  microscopical  study  nearly  always 
reveals  the  characteristic  lesions  of  tuberculosis;  and  in  some  cases 
where  no  histological  indication  of  tuberculosis  was  found,  inoculation 
experiments  have  been  positive.1 


Fig.  798. — Tuberculous  cervical  adenitis 
(submaxillary  and  subparotid).  Duration  six 
months.  No  softening  yet.  Children's 
Hospital. 


Fig.  799. — Tuberculous  cervical 
adenitis.  Age  twenty-five  years; 
duration  three  years,  no  sinus. 
From  carious  teeth.  Orthopaedic 
Hospital. 


Tuberculous  Lymphadenitis. — Tuberculous  lymphadenitis  in  the  neck 
is  an  exceedingly  common  affection.  For  anatomical  reasons,  the 
subparotid  and  submaxillary  lymph  nodes,  draining  the  tonsils,  teeth, 
and  anterior  portions  of  the  scalp,  are  those  most  often  primarily 
involved  (Fig.  798) .  Thence  the  disease  spreads  to  the  upper  deep  cer- 
vical lymph  nodes,  travels  along  those  accompanying  the  internal  jugu- 
lar vein  to  the  clavicle,  and  often  invades  the  supraclavicular  group. 

1  Such  cases  are  one  form  of  "inflammatory  tuberculosis"  described  by  Poncet 
and  Leriche. 


72G  SURGERY  OF  THE  FACE,   MOUTH,  AND  NECK 

Tuberculous  cervical  adenitis  occurs  ol'tcncst  in  those  from  fifteen  to 
twenty  years  of  age,  and  is  commoner  in  those  under  fifteen  than  in 
those  past  twenty-five  years  of  age.  It  may  affect  one  or  both  sides  of 
the  neck.  Usually,  as  noted  above,  there  have  been  one  or  more  attacks 
of  acute  adenitis — seldom  so  acute  as  to  lead  to  suppuration,  and  often 
so  subacute  as  to  have  required  no  medical  attention,  the  child  being 
"doctored"  at  home  with  ham  fat  or  goose  grease.  Such  attacks  often 
date  from  the  period  of  convalescence  following  measles  or  other  acute 
exanthem.  Finally  the  nodes  become  so  conspicuous,  or  so  constantly 
tender,  even  if  invisible  to  a  casual  glance,  that  medical  attention  is 
sought.  The  nodes  are  now  more  or  less  discrete,  movable,  elastic,  but 
tender;  they  do  not  feel  hot,  and  give  no  evidence  of  fluctuation.  They 
vary  from  pea-size  to  that  of  a  walnut,  seldom  larger.  Almost  always 
there  are  a  great  many  more  present  than  can  be  detected  by  clinical 
examination.  When  the  affection  is  of  still  longer  duration  the  sur- 
geon finds,  instead  of  discrete,  elastic,  and  movable  nodes,  that  there 
are  ill-defined,  more  or  less  immovable  masses,  evidently  composed 
of  several  coalesced  nodes  (Fig.  799);  in  one  or  two  places  there  may 
be  evidence  of  softening.  At  a  still  later  stage,  cold  abscesses  form, 
spontaneous  fistulization  may  occur,  and  the  neck  is  riddled  with 
sinuses,  each  separate  and  distinct  node  as  it  softens  discharging 
through  a  new  orifice  (see  Fig.  36).  If  secondary  pyogenic  infection 
occurs,  a  hectic  state  may  develop. 

The  diagjiosis  must  be  made  from  Hodgkin's  disease  and  from 
malignant  or  syphilitic  enlargements.  A  differential  diagnosis  from 
chronic  non-tuberculous  inflammation  usually  is  impossible,  at  least 
in  the  early  stages  of  tuberculosis,  except  from  the  results  of  treat- 
ment, or  by  laboratory  examination  of  an  excised  specimen.  If  cure 
of  the  infecting  focus  and  non-operative  care  of  the  neck  causes  nodes 
to  become  no  longer  palpable,  it  may  be  assumed  that  the  condition 
was  not  tuberculous,  or  only  very  slightly  so.  Hodgkin's  disease 
usually  is  easily  recognized  by  the  firmness  of  the  nodes,  their  tendency 
to  enlarge  without  coalescing  or  softening,  and  by  involvement  of 
other  groups  of  lymph  nodes  as  well  as  the  cervical.  Carcinoma  is 
secondary  to  a  growth  elsewhere,  though  this  growth  may  have  been 
excised  many  years  previously,  and  there  may  be  no  local  recurrence 
and  an  inconspicuous  scar.  Such  lymph  nodes  are  hard  and  not  tender, 
and  the  patients  are  very  rarely  indeed  of  an  age  wThen  tuberculous 
adenitis  is  frequent.  Sarcoma  of  the  cervical  lymph  nodes  is  rare. 
In  its  early  stages  it  resembles  clinically  a  case  of  Hodgkin's  disease, 
but  affects  only  the  cervical  lymph  nodes;  it  never  suppurates,  but 
tends  to  involve  the  skin,  and  to  form  a  fungous  ulcer.  It  is  important 
to  recognize  the  existence  of  syphilis,  particularly  the  hereditary  form, 
in  cases  of  the  cervical  lymph  nodes.  It  occurs  about  puberty,  and 
its  syphilitic  nature  should  be  suspected  from  the  presence  of  other 
signs  of  the  disease  (Fig.  1028). 

Prognosis  and  Treatment. — -The  prognosis  of  tuberculous  cervical 
adenitis  is  bad,  unless  it  is  properly  treated.    Not  only  does  the  local 


SURGERY  OF  THE  NECK 


727 


condition  go  from  bad  to  worse,  but  the  patient's  general  health 
steadily  deteriorates.  Statistics  collected  in  1905  by  Dowd,  and  so 
far  as  I  know  not  since  contradicted,  showed  that  without  operation, 
but  with  medical  treatment  only,  from  21  to  25  per  cent,  of  these 
patients  ultimately  develop  phthisis.  This  is  small  wonder,  when 
the  drainage  of  the  cervical  lymph  nodes  into  the  right  heart  is  remem- 
bered. In  1909  Dowd  traced  ninety-six  patients  on  whom  he  had 
operated  more  than  three  years  previously.  He  found  nearly  94  per 
cent,  apparently  cured;  one  death;  and  five  patients  with  recurrence 
which  could  be  cured  by  operation.  No  other  form  of  treatment  gives 
such  satisfactory  results.  Even  in  children,  in  whom  temporizing  and 
medical  methods  often  are  regarded  as  more  legitimate  in  this  affection 
than  in  adults,  the  prognosis  is  better  if  the  diseased  lymph  nodes  are 


Fig.  800.  —  Tuberculous  cervical 
lymph  nodes;  duration  six  months, 
following  measles.  (See  Figs.  801, 
802,  and  803.)      Children's  Hospital. 


Fig.  801.— Same  patient  as  Fig.  800, 
after  operation,  showing  temporary  para- 
lysis of  depressor  anguli  oris.  (See  also 
Figs.  802    and   803.)     Children's   Hospital. 


removed  by  operation.  But  in  every  case  the  source  of  infection  must 
be  cured.  No  matter  how  thorough  the  operation,  if  the  infecting  focus 
remains  in  scalp,  tonsil,  pharynx,  or  elsewhere,  other  nodes  not  detected 
at  the  first  operation  will  become  diseased,  and  the  patient  will  be  no 
better  off  than  before  the  first  operation.  If  there  are  chronically 
enlarged  lymph  nodes  in  the  neck,  the  first  thing  to  do  is  to  cure  the 
source  of  infection;  the  lymph  nodes  may  then  cease  to  give  symptoms. 
If  they  do  not,  they  almost  certainly  are  tuberculous,  and  should  be 
removed.  Occasionally  the  lymphatic  invasion  is  so  much  more 
disabling  than  the  source  from  which  the  infection  is  derived,  that  it 
is  justifiable  to  do  the  operation  on  the  cervical  lymphatics  first, 
and  to  postpone  cure  of  the  nasal  or  tonsillar  or  dental  or  scalp  con- 
dition, until  comparative  health  has  been  restored;  but  in  many  such 
cases  a  recurrence  in  the  neck  will  take  place   because  the  infecting 


'2S 


SURGERY   OF   THE   FACE,   MOUTH,   AND  NECK 


focus  is  too  long  neglected.  Seldom  or  never  is  it  advisable  to  under- 
take a  nose  or  throat  operation  at  the  same  time  that  the  neck  opera- 
tion is  done.  If  there  are  adenoids,  enlarged  tonsils,  etc.,  it  is  better 
to  attend  to  them  one  or  two  weeks  before  the  neck  operation  is  done; 


Fig.  802. — Same  patient  as  Fig.  800,  showing  Dowel's  incision  for  cervical 
adenitis.     Children's  Hospital. 

and  a  week  or  ten  days  usually  should  elapse  between  operations  if 
both  sides  of  the  neck  are  involved.  The  neck  operation  frequently 
is  one  of  great  difficulty,  and  if  properly  done  always  is  tedious  and 
lengthy  (Figs.  800,  801,' 802,  and  803). 

Operation. — If  the  nodes  only  in  the  upper  portion  of  the  neck  are 
involved,  they  may  be  reached  conveniently  through  Dowd's  upper 


Fig.  803. — Mass  of  tuberculous  lymph  nodes  removed  entire,  showing  groove  for 
great  vessels  (three-fourths  natural  size).  (See  Figs.  800,  801,  and  802.)  Children's 
Hospital. 

incision,  which  runs  in  the  direction  of  the  folds  of  the  neck  about 
3  cm.  below  the  jaw  (Fig.  802).  Cut  through  the  platysma  and  deep 
fascia  before  reflecting  the  margins  of  the  wound,  so  as  to  avoid  injury 
to  the  branch  of  the  facial  nerve  which  supplies  the  depressor  labii 


SURGERY  OF  THE  NECK  729 

inferioris;  this  nerve  runs  between  the  deep  fascia  and  platysma,  about 
a  finger's  breadth  below  the  mandible,  and  is  the  only  branch  of  the 
facial  nerve  exposed  to  injury  (Fig.  801).  Then  identify  the  anterior 
border  of  the  sternornastoid  muscle,  and  work  under  its  margin  until 
the  carotid  sheath  is  exposed  below  the  enlarged  lymph  nodes.  These 
should  then  be  removed  by  careful  dissection  (not  blunt  tearing)  from 
below  upward,  in  one  mass  (Fig.  803).  The  chief  dangers  are  hemor- 
rhage from  large  branches  of  the  internal  jugular  vein,  especially  the 
facial  and  temporo-maxillary  veins;  and  injury  to  important  nerves, 
notably  the  hypoglossal  and  spinal  accessory. 

If  the  lower  deep  cervical  lymph  nodes  are  involved,  a  second  trans- 
verse incision,  parallel  to  the  first,  and  several  inches  lower,  may  be 
added.  These  nodes  are  most  easily  exposed  along  the  posterior  border 
of  the  sternornastoid  muscle.  As  one  works  along  this  from  below 
upward,  the  first  nerves  encountered  are  branches  of  the  superficial 
cervical  plexus,  emerging  about  the  middle  of  the  posterior  border  of 
the  sternornastoid ;  and  about  2  cm.  higher  up  the  spinal  accessory  is 
encountered  as  it  leaves  this  muscle  and  crosses  the  posterior  cervical 
triangle  to  the  trapezius  muscle.  The  sensory  nerves  may  be  sacri- 
ficed, but  the  spinal  accessory  should  be  preserved. 

In  cases  where  there  is  very  extensive  involvement,  including  the  supra- 
clavicular nodes,  and  where  the  tissues  are  densely  adherent,  it  is 
better  to  use  the  incisions  advised  in  operating  for  carcinoma  (Fig. 
780).  The  dissection  is  begun  at  the  clavicle  and  proceeds  upward, 
the  diseased  tissue  being  removed  in  one  mass.  If  the  surgeon  can 
once  lay  bare-  the  prevertebral  muscles  he  will  be  able  to  remove 
the  entire  lymphatic  area  of  the  neck.  In  exceptional  cases  trans- 
verse division  of  the  sternornastoid  muscle  may  be  necessary.  The 
existence  of  a  cold  abscess  or  even  of  a  sinus,  if  uninfected,  does  not 
interfere  with  repair  of  the  wound. 

The  wound  should  be  closed  with  two  layers  of  sutures,  the  first 
to  the  platysma  and  fascia,  and  the  second  in  the  skin.  Neglect  to 
suture  the  platysma  separately  allows  stretching  even  of  a  transverse 
scar.  Drainage  should  be  provided  for  by  small  tube,  for  the  first 
few  days;  and  after  extensive  operations  the  patient's  head  should  be 
immobilized  by  sand-bags  until  healing  is  well  under  way. 

Tumors  of  the  Carotid  Body  or  Gland  usually  are  clinically  malig- 
nant. Pathologically  they  are  peritheliomas  or  endotheliomas.  The 
tumor  occurs  in  young  adults,  and  is  slow-growing,  painless,  dense, 
and  non-inflammatory.  Its  clinical  course  extends  through  many 
years,  but  sudden  growth  may  develop  at  any  time.  Eventually 
the  growth  surrounds  and  compresses  the  carotid  arteries,  and  causes 
symptoms  from  pressure,  especially  from  pressure  on  the  sympathetic, 
hypoglossal,  and  vagus  nerves.  The  diagnosis  is  made  chiefly  by  exclu- 
sion. The  tumor  is  situated  at  the  bifurcation  of  the  common  carotid 
artery,  and  receives  transmitted  pulsation;  but  this  pulsation  is  not 
expansile,  and  there  is  no  thrill  nor  bruit.  Compression  of  the  com- 
mon carotid  artery  does  not  affect  the  tumor.    The  absence  of  primary 


730 


SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 


growth  elsewhere,  the  long  duration,  and  the  younger  age  of  the 
patient,  exclude  carcinoma.  Sarcoma  grows  much  more  rapidly,  and 
tends  to  soften  and  ulcerate. 

Treatment. — If  seen  very  early,  extirpation  may  be  undertaken; 
but  very  soon  the  operation  becomes  one  of  the  utmost  difficulty  and 
great  danger.  The  mortality  thus  far  is  about  25  per  cent.  Operation 
usually  involves  ligation  of  the  common  carotid  artery  below  and  of 
the  external  and  internal  carotids  above  the  growth,  for  it  cannot  be 
separated  from  them  safely.  Other  structures  should  be  preserved  if 
possible.  In  one  case  it  was  necessary  to  remove  part  of  the  base  of 
the  skull  to  secure  the  internal  carotid  above  the  growth;  and  irre- 
parable damage  has  been  done  to  both  recurrent  and  superior  laryn- 
geal nerves,  to  the  hypoglossal  and  even  the  facial  nerve.  If  it  appear 
improbable  that  the  operation  can  be  completed,  it  should  not  be 
attempted,  or  if  begun,  should  be  abandoned  in  good  time. 


Fig.  804. — Thyroglossal  cyst:  at 
birth  size  of  walnut;  steady  growth 
since.  Age  four  years.  Orthopaedic 
Hospital. 


Fig.  805. — Thyroglossal  cyst;  age  four 
years.     Orthopaedic  Hospital. 


Thyroglossal  Cysts  and  Fistulae. — The  thyroglossal  duct  in  the 
embryo  runs  from  the  foramen  cecum  of  the  tongue  through  or  behind 
the  hyoid  bone,  in  the  mid-line  of  the  neck,  to  the  thyroid  gland.  If 
the  duct  fails  to  be  obliterated,  any  portion  which  remains  may  become 
dilated  and  form  a  cyst;  and  if  the  cyst  ruptures  externally  a  fistula 
will  result.  These  cysts  and  fistula?  always  are  in  the  median  line  of 
the  neck.  They  may  be  above  the  hyoid  bone,  over  it,  below  it,  or 
the  entire  thyro-glossal  duct  may  be  persistent.  Usually  these  cysts 
are  noted  in  childhood  (Figs.  804  and  805),  but  sometimes  no  trace  of 
them  is  observed  until  puberty  (Figs.  806  and  807).  The  cyst  slowly 
and  painlessly  increases  in  size,  and  relief  is  sought  for  deformity  or 
pressure  effects.  A  thyroglossal  fistula  secretes  a  little  mucoid  matter ; 
pain  may  result  from  retention  of  its  contents  if  the  orifice  becomes 
scabbed.     Suprahyoid  cysts  are  lined  by  stratified  squamous  epithe- 


SURGERY  OF  THE  NECK 


731 


Hum;   those  arising  lower  in  the  thyroglossal    tract    are   lined  by 
columnar  (sometimes  ciliated)  epithelium. 

Treatment.— Extirpation  should  be  done,  removing  carefully  every 
trace  of  the  duct  wall.  Recurrence  will  take  place  if  any  portion 
remains.  The  dissection  is  difficult  and  should  not  be  undertaken 
by  an  unskilled  operator. 


Fig.  806. — Thyroglossal  cyst,  age 
fourteen  years;  duration  one  year. 
Episcopal  Hospital. 


Fig.  807. — Thyroglossal  cyst.     Same  patient 
as  Fig.  806.     Episcopal  Hospital. 


Branchial  Cysts  and  Fistulse. — These  result  from  maldevelopment 
of  the  branchial  arches  and  clefts  of  embryonic  life.  They  are  situated 
laterally  in  the  neck,  and  thus  are  easily  distinguished  from  the  median 
thyroglossal  remains.  Branchial  fistulse  usually  open  along  the  anterior 
border  of  the  sternomastoid  muscle,  and  may  extend  as  far  as  or 
even  into  the  pharynx.  The  condition  is  congenital,  but  the  patient 
may  not  seek  relief  until  adult  life,  and  the  cysts  may  be  of  insignifi- 
cant size  until  the  occurrence  of  some  injury  (Fig.  808).  If  the  cyst 
lies  near  the  pharynx  it  will  have  lymphoid  tissue  in  its  walls. 

Treatment. — Extirpation,  which  is  the  only  successful  treatment, 
involves  a  very  much  more  delicate  dissection  than  that  of  the  median 
cysts  already  mentioned;  and  even  skilled  dissectors  may  have  to 
repeat  the  operation  a  number  of  times.  Distending  the  sinus  with 
paraffin,  which  is  injected  hot  and  allowed  to  harden  in  situ,  is  a 
valuable  aid. 

Branchiogenic  Carcinoma  (Langenbeck,  1861;  Volkmann,  1882). — 
Occasionally  a  carcinoma  develops  in  a  branchial  cleft  (Fig.  809.)  Diag- 
nosis before  operation  is  difficult.  It  may  resemble  a  tumor  of  the  carotid 
body,  but  occurs  in  older  persons,  its  duration  is  measured  by  weeks 
or  months,  seldom  by  years,  and  it  may  become  adherent  to  the  skin. 
Treatment  involves  extirpation  of  the  tumor  with  the  overlying  skin. 


732  SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 

In  the  aged  it  is  well  to  test  the  collateral  circulation  by  applying  a 
temporary  clamp  to  the  common  carotid  artery  for  a  few  days  before 
operation,  since  its  extirpation  may  be  required  (p.  134). 


Fig.  808. — Branchial  cyst  of  neck;  age 
eighteen  years;  duration  seven  months; 
followed  a  fall.     Orthopaedic  Hospital. 


Fiu.  809. — Branchiogenic  carcinoma. 
Age  sixty-one  years.  Duration  three 
years.     Episcopal  Hospital. 


Hygroma. — This  is  an  old  clinical  term  used  to  describe  cervical 
cysts  of  different  nature.  The  subject  has  been  studied  recently  by 
Dowd  (1913).  Some  are  lymphangeiomatons  in  character:  these  are 
congenital,  usually  occupy  the  posterior  triangle,  seldom  cause  dis- 
ability, often  grow  smaller  and  may  even  disappear  as  the  patients 
grow  older.  Their  removal  is  difficult  and  dangerous,  and  should  not 
be  attempted  unless  pressure  symptoms  render  relief  imperative. 
Often  the  most  that  can  be  done  is  to  excise  the  anterior  and  parts 
of  the  lateral  walls  of  the  cyst,  and  pack  its  cavity  with  gauze,  looking 
for  a  cure  by  granulation,  cicatrization,  and  contraction.  Occasion- 
ally the  cyst  extends  into  the  axilla.  Hemorrhagic  cysts  may  result 
from  traumatic  or  spontaneous  hemorrhage  into  a  preexisting  cyst. 
Bursal  cysts,  occurring  in  preexisting  bursas  around  the  hyoid  bone 
or  thyroid  cartilage,  result  from  effusion  due  to  trauma  or  constitu- 
tional disease.     (See  also  Ranula,  p.  692). 

Lipoma  is  frequent  in  the  neck.  Fibroma  is  rather  unusual;  it  gen- 
erally springs  from  the  deep  fascia,  is  slow  growing;  may  in  time 
undergo  degenerative  changes,  and  reach  an  immense  size. 


SURGERY  OF  THE  THYROID  GLAND. 

Inflammation. — Inflammation  of  the  normal  thyroid  gland  is  com- 
paratively rare.     It  is  described  as  thyroiditis,  and  must  be  distin- 


SURGERY  OF  THE  THYROID  GLAND  733 

guished  from  strumitis,  or  inflammation  of  a  goitrous  gland  (p.  736). 
Acute  thyroiditis,  seldom  leading  to  abscess,  occurs  by  infection 
through  the  blood-stream  in  general  infections  such  as  typhoid  fever, 
scarlatina,  etc.  The  entire  gland  is  enlarged  and  tender,  and  pressure 
symptoms  are  usual.  If  suppuration  is  suspected  an  incision  should 
be  made.  If  multiple  abscesses  exist,  or  if  necrosis  occurs,  partial 
excision  should  be  done.  Chronic  thyroiditis  is  much  less  unusual  than 
the  acute,  and  usually  is  chronic  from  the  start,  seldom  following  an 
acute  attack.  It  occurs  usually  in  alcoholic  or  arteriosclerotic  adults, 
and  may  be  caused  by  syphilis  (gummatous  form),  tuberculosis,  or 
prolonged  use  of  iodin.  Operation  may  be  required  for  diagnosis 
in  cases  of  asymmetrical  involvement  of  the  gland,  or  to  relieve  pres- 
sure. Ligneous  or  woody  thyroiditis  (Riedel,  1896)  is  believed  by  Delore 
and  Alamartine  (1911)  at  times  to  be  one  of  the  manifestations  of 
what  Poncet  called  inflammatory  tuberculosis.  Clinically  the  diagnosis 
from  carcinoma  is  difficult,  and  pathologists  interpret  the  histological 
pictures  differently.  Compression  of  the  trachea  is  frequent,  and 
demands  intervention.  This  should  consist  merely  in  resection  of  the 
thyroid  isthmus.  Radical  operation  is  nearly  impossible  and  is  not 
necessary.  The  use  of  the  .x-ray  may  hasten  regression  of  the  disease. 
Goiter. — This  is  a  clinical  term  used  to  describe  an  enlargement 
of  the  thyroid  gland.  It  is  derived  from  the  Latin  word  for  throat 
(guttur).  The  thyroid  is  an  epithelial  gland  which  in  embryonic  life 
had  a  duct,  the  thyroglossal  duct.  The  presence  or  absence  of  a  goiter, 
and  the  existence  or  non-existence  of  constitutional  symptoms  in  con- 
nection with  it,  depend  on  the  inter-relation  of  secretion  and  absorp- 
tion in  the  thyroid  gland.  In  fetal  life  there  is  little  or  no  evidence  of 
secretion.  At  puberty  the  thyroid  becomes  more  active,  and,  as  noted 
below,  sometimes  enlarges.  In  adult  life  whatever  secretion  is  pro- 
duced is  normally  absorbed  by  the  body  tissues.  In  abnormal  states 
there  is  excess  of  secretion,  and  this  is  either  not  so  absorbed,  and 
accumulates  in  the  thyroid  ("cystic"  goiter);  or  else  is  absorbed  and 
produces  toxemia  (hyperthyroidism).  Whenever  hyperthyroidism 
exists  there  is  an  increase  in  the  secreting  surface  of  the  thyroid; 
this  results  either  in  a  parenchymatous  hypertrophy  (without  cyst 
formation),  or  in  intracystic  papillomatous  out-growths  (if  the  change 
occurs  in  a  thyroid  previously  cystic).  When  instead  of  paren- 
chymatous hypertrophy,  there  is  marked  increase  in  the  interglandular 
connective  tissue,  the  amount  of  secreting  surface  is  relatively 
decreased ;  this  is  the  case  in  the  thyroids  of  cretins  (hypothyroidism) 
and  the  term  hypertrophic  fetal  thyroid  is  applied.  If  in  a  fetal  type 
of  thyroid  the  epithelial  (secreting)  elements  are  in  excess,  we  have 
an  adenomatous  thyroid,  and  symptoms  of  hyperthyroidism  may  or 
may  not  be  present.  Patients  in  whom  atrophy  of  secreting  cells  has 
occurred,  usually  as  the  result  of  pressure  from  accumulated  and  not 
absorbed  secretion  (chiefly,  therefore,  in  cases  of  cystic  thyroid),  are 
those  who  are  spontaneously  cured  of  their  toxic  symptoms;  in  some 
such  cases  the  final  state  may  be  one  of  hypothyroidism  (MacCarty, 
1910). 


734 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


Physiological  enlargement    of  the  thyroid    gland    often   occurs   in 
girls  at  puberty,  the   enlargement   persisting   for   a   year   or   more 

and  then  gradually  subsiding. 
Sometimes  enlargement  recurs  at 
every  menstrual  period  or  during 
pregnancy;  and  occasionally  the 
enlargement  which  appeared  at 
puberty  never  subsides.  The 
gland  is  uniformly  and  symmetric- 
ally enlarged.  No  symptoms  are 
present  and  the  patient  may  not 
be  aware  of  the  existence  of  a  goiter. 
No  treatment  is  required. 

Pathological  enlargement  of  the 
thyroid  gland  is  endemic  in  certain 
regions,  notably  in  Switzerland:  it 
is  frequent  in  French  Canada,  and 
in  some  other  parts  of  North 
America.  It  is  generally  believed 
that  this  enlargement  is  associated 
in  some  way  with  the  drinking 
water  of  the  patients ;  and  it  seems 
Fig.   8io—  'Nodular"    goiter   in   a     probable   that  the  cause   is  some 

woman  aged  forty  years.     Duration  five  ...      '.  ,  .,         .     ,. 

years.     Orthopedic  Hospital.  qualitative     change     111     the     lodin 

constituents  of  the  drinking  water. 
The  enlargement  may  be  diffuse  or  circumscribed  ("  nodular")  (Fig.  810.) 
This  classification  of  Kocher  is  in  general  use,  and  is  very  convenient 
for  purposes  of  clinical  study. 

Diffuse  enlargement  involves  both  lateral  lobes  and  isthmus  pro- 
portionately. It  usually  is  due  to  more  or  less  uniform  increase  in 
all  the  elements  of  the  thyroid  (follicular  and  'parenchymatous  goiter) 
or  to  disproportionate  increase  in  the  colloid  material  (colloid  goiter). 
In  the  latter  and  more  frequent  form,  the  consistency  of  the  swelling 
is  harder,  and  the  individual  lobules  appear  larger  and  are  more 
easily  defined.  A  diffuse  vascular  goiter  is  one  of  any  form  in  which 
vascularity  is  marked.  A  diffuse  fibrous  goiter  is  the  result  of  inflam- 
mation and  cicatricial  changes  in  any  of  the  forms  mentioned,  and  is 
very  rare.  There  is  also  a  form  of  diffuse  adenomatous  goiter  which 
it  is  better  to  classify  among  malignant  growths. 

Circumscribed  or  nodular  enlargement  may  occur  in  any  of  the  prin- 
cipal forms  already  mentioned:  follicular,  colloid,  or  adenomatous. 
The  colloid  or  "  cystic"  goiter  is  by  far  the  most  frequent  form.  Nodu- 
lar goiter  is  characterized  (1)  by  the  irregularity  and  inequality  of 
the  enlargements;  and  (2)  by  their  tendency  to  undergo  degenerative 
changes,  such  as  colloid,  hyaline,  calcareous,  etc.,  and  to  intra  cystic 
hemorrhages.  Single  nodules  are  most  common  in  one  of  the  lower 
poles  of  the  lateral  lobes;  occasionally  they  occur  in  one  of  the  upper 
poles;  and  very  rarely  in  the  isthmus  or  in  the  pyriform  lobe  when 


SURGERY  OF  THE  THYROID  GLAND 


735 


the  latter  is  present.  Multiple  nodules  may  exist.  As  the  nodules 
increase  in  size  they  displace  the  remaining  normal  gland  structure, 
and  may  become  more  or  less  encapsulated.  Occasionally  a  diffuse 
colloid  goiter  is  converted  into  a  goiter  with  multiple  cystic  nodules; 
these  have  little  tendency  toward  degeneration  or  internal  hemor- 
rhages. 

Symptoms  and  Diagnosis. —  Diffuse  goiter  retains  the  shape  of  the 
normal  gland,  and  rarely  attains  very  large  size.  The  tumor,  as  in 
all  thyroid  affections,  rises  with  the  larynx  in  the  act  of  swallowing  and 
in  coughing.  It  is  movable  laterally,  but  scarcely  at  all  up  and  down. 
Pressure  symptoms  are  rare.  Sometimes  venous  engorgement  is  visible 
over  the  root  of  the  neck  or  upper  thorax.  In  nodular  goiter  the  relation 
of  the  swelling  to  the  thyroid  is  determined  by  its  location  in  the  neck 
over  the  normal  site  of  the  thyroid, 
and  by  its  movement  with  the  larynx 
in  deep  breathing,  swallowing,  and 
coughing.  The  swelling  is  close  to 
the  median  line  of  the  neck,  but 
usually  is  distinctly  lateral  in  its  at- 
tachment. As  it  increases  in  size  it 
may  become  pendulous  (Fig.  811).  It 
pushes  forward  the  sub-hyoid  muscles, 
and  displaces  the  sternomastoid 
muscle  and  great  vessels  of  the  neck 
laterally,  so  that  the  vessels  may  be 
palpable  at  the  posterior  border  of 
this  muscle;  it  may  distort  or  com- 
press the  trachea  and  esophagus;  and 
may  cause  symptoms  from  pressure 
on  the  sympathetic,  recurrent,  or 
superior  laryngeal  nerves.  Rarely  a 
goiter  may  grow  down  behind  the  ster- 
num, when  its  presence  may  be  detected  by  percussion.  Finally,  a  goiter 
may  produce  disturbance  of  the  heart  and  circulation,  either  directly 
by  pressure  on  the  great  vessels,  or  through  interference  with  respira- 
tion; or  in  some  instances  from  hyperthyroidism  (p.  737).  Intermit- 
tent pressure  on  the  great  vessels  of  the  neck  may  produce  giddiness 
and  other  evidences  of  disturbances  in  the  intracranial  circulation. 

In  diffuse  follicular  and  in  parenchymatous  goiters  the  diagnosis 
rests  on  the  soft,  flabby  consistency,  palpation  of  the  small  but  rather 
distinct  lobules,  and  the  vascularity.  Early  symptoms  of  hyper- 
thyroidism may  be  present,  and  these  usually  will  be  increased  by  the 
administration  of  iodin.  The  diffuse  colloid  goiter  is  relatively  firm, 
the  lobules  are  much  larger,  and  some  are  quite  hard ;  iodin  causes  no 
diminution  in  size.  The  diffuse  fibrous  goiter  is  harder,  and  there  are 
symptoms  of  hypothyroidism. 

In  nodular  colloid  goiter  (cystic  goiter)  the  diagnosis  often  is  made  at 
a  glance.    The  surface  of  the  cyst  is  smooth,  its  form  is  oval  or  rounded, 


Fig.  811.— Cystic  goiter,  of  sixteen 
years'  duration  in  a  patient  of  thirty- 
seven  years.     Pennsylvania  Hospital. 


736  SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 

and  its  consistency  elastic.    The  adenomatous  goiter  is  recognized  by 
its  circumscribed  character,  and  its  soft  and  doughy  feel. 

Treatment. — In  many  cases  of  diffuse  goiter,  judicious  medical  treat- 
ment, with  attention  to  hygiene,  will  cause  diminution  or  complete 
subsidence  of  the  swelling.  Operation  is  required  only  for  cosmetic 
effect,  to  relieve  pressure  symptoms,  or  to  check  progressive  growth 
or  a  tendency  toward  hyperthyroidism.  In  most  cases  of  nodular 
goiter  operation  is  indicated  at  an  early  stage,  for  the  same  reasons 
which  render  its  adoption  advisable  at  a  later  stage  in  the  diffuse  form. 
This  is  particularly  true  of  nodules  undergoing  degenerative  changes, 
and  especially  of  the  nodular  adenomatous  form,  since  in  this  the  ten- 
dency to  malignant  change  is  well  marked.  Finally,  it  may  be  stated 
in  general  terms,  that  any  goiter  of  rapid  growth  or  tender  on  pressure 
should  be  referred  to  the  surgeon. 

The  operation  consists  in  excision  of  the  affected  lobe;  or  in  case  of 
one  or  twro  large  nodules,  in  their  enucleation;  as  the  nodules  usually 
are  fairly  well  encapsulated  the  remainder  of  the  gland  may  be  left 
intact,  to  prevent  development  of  symptoms  of  hypothyroidism. 
Enucleation  is  indicated  especially  where  it  is  probable  that  very 
little  healthy  functionating  gland  tissue  remains.  In  diffuse  goiter 
it  usually  is  found  sufficient  to  excise  one  lobe,  with  a  part  of  the  isth- 
mus; the  remaining  lobe  may  then  cease  to  cause  symptoms.  Should 
these  continue,  a  part  or  whole  of  the  second  lobe  may  be  removed 
subsequently.  Rocker's  incision  is  a  transverse  incision,  slightly 
convex  downward,  crossing  the  neck  over  the  prominence  of  the 
thyroid,  from  one  sternomastoid  muscle  to  the  other.  In  operations 
on  one  lobe  only,  the  incision  need  be  only  half  as  long.  The  flaps, 
including  platysma  and  fascia,  are  then  dissected  upward  and  down- 
ward, exposing  the  pre-thyroid  muscles.  These  may  be  divided  near 
the  hyoid  bone,  if  necessary,  thus  preserving  their  nerve  supply,  and 
the  tumor  may  then  be  dislocated  into  the  wound.  In  all  thyroid- 
ectomies, partial  or  complete,  hemorrhage  should  be  scrupulously 
avoided,  by  clamping  and  ligating  veins  as  they  are  encountered,  and 
securing  the  superior  and  inferior  thyroid  arteries  of  the  affected  lobe 
before  its  excision  is  begun.  The  superior  pole  should  be  delivered 
first,  and  the  artery  ligated  close  to  the  gland.  In  delivering  the  in- 
ferior pole,  damage  to  the  recurrent  laryngeal  nerve  and  the  inferior 
parathyroid  (p.  739)  should  be  avoided.  Then  the  capsule  of  the  gland 
is  split  open  along  its  lateral  aspect,  and  the  lobe  is  removed,  leaving 
part  of  it  adherent  to  the  posterior  portion  of  the  capsule,  so  as  to 
avoid  injury  to  the  parathyroid  glandules  and  the  recurrent  laryngeal 
nerve.  The  occasional  presence  of  a  thyroidea  ima  artery  should 
be  remembered.  The  isthmus  is  clamped  and  is  ligated,  in  the  groove 
made  by  the  clamp,  before  it  is  divided.  Severed  muscles  are  then 
sutured,  and  the  wound  is  closed  with  ample  drainage. 

Strumitis. — Inflammation  of  a  goitrous  thyroid  is  less  unusual  than 
that  of  the  normal  gland.  The  diagnosis  rarely  is  difficult,  and  the 
treatment  is  the  same  as  for  corresponding  forms  of  thyroiditis. 


SURGERY  OF  THE  THYROID  GLAND  737 

Hypothyroidism. — In  persons  from  whom  the  entire  thyroid  gland 
is  removed  there  usually  develops  a  condition  of  acquired  cretinism, 
known  as  myxedema,  or  cachexia  thyreopriva.  The  signs  of  this  con- 
dition need  not  be  detailed  here.  A  knowledge  of  the  condition 
is  sufficient  to  warn  the  operator  not  to  remove  all  the  function- 
ating thyroid  tissue.  If  this  course  has  to  be  pursued  in  the  eradi- 
cation of  malignant  disease,  the  patient  should  ingest  daily  a  sufficient 
quantity  of  thyroid  extract  to  keep  the  myxedematous  symptoms  in 
abeyance.  Transplantation  of  thyroid  tissue,  from  man  and  from  some 
lower  animals,  has  been  tried  in  such  cases,  and  in  some  instances 
with  encouraging  results.  The  portions  of  thyroid  gland  have  been 
implanted  subcutaneously,  in  the  subserous  tissues,  in  the  splenic 
pulp,  and  in  the  bone  marrow.  In  most  cases,  even  if  the  graft 
functionates  properly  for  a  time,  it  eventually  is  absorbed,  and 
myxedematous  symptoms  again  develop. 

Hyperthyroidism  (Exophthalmic  Goiter,  Graves's  Disease  (1835), 
Basedow's  Disease  (1840),  Thyrotoxicosis). — Administration  of  thyroid 
extract  in  excess  to  normal  persons  causes  the  development  of  certain 
symptoms  which  are  also  present  in  some  diseased  states  of  the  thyroid 
gland.  These  symptoms  are  the  direct  antithesis  of  those  observed 
in  myxedema.  They  may  be  grouped  in  four  main  categories:  (1) 
Local  changes  in  the  thyroid.  (2)  General  circulatory  symptoms.  (3) 
Nervous  symptoms.  (4)  Metabolic  changes.  There  should  also  be 
mentioned  exophthalmos,  which  usually  is  present,  but  sometimes  is 
not  associated  with  other  typical  symptoms. 

The  affection  is  much  commoner  in  women  than  in  men  (about 
6  to  1),  and  occurs  usually  between  the  ages  of  fifteen  years  and  thirty- 
five  years;  it  is  less  rare  after  thirty-five  years  than  before  puberty. 
It  appears  to  be  induced  by  physical  or  mental  exhaustion,  worry, 
anxiety,  fright,  fear,  etc.  Sometimes  it  develops  very  acutely;  in 
others  very  rapidly,  but  not  suddenly;  at  other  times  its  onset  is 
insidious.  In  the  cases  which  develop  rapidly,  the  goiter  usually 
makes  its  first  appearance  at  the  time  that  the  thyrotoxic  symptoms 
develop;  in  the  chronic  cases,  with  slow  onset,  a  goiter  usually  has 
been  present  for  months  or  years  before  hyperthyroidism  ensues. 

Local  Changes. — The  thyroid  usually  is  enlarged  symmetrically 
and  diffusely.  Its  vascularity  is  increased,  giving  it  a  soft  feel;  but 
deep  pressure  detects  a  gland  firmer  than  normal.  Nodular  goiter 
rarely  is  associated  with  thyro-toxic  symptoms.  The  more  acute 
the  onset,  the  more  marked  are  the  local  changes.  In  cases  of  long 
duration,  especially  when  medical  treatment  has  been  prolonged, 
the  gland  becomes  smaller  and  firmer,  but  the  vascular  phenomena 
may  be  demonstrated  again  after  excitement.  In  some  cases  no  local 
changes  are  perceptible,  and  the  diagnosis  depends  on  other  signs. 

Circulatory  Symptoms. — Tachycardia  is  the  most  prominent  symp- 
tom: the  pulse  is  abnormally  frequent,  quick,  usually  of  high  tension, 
and  extremely  irritable  (A.  Kocher).  These  changes  may  be  acute 
in  onset,  or  very  gradually  develop.  Excitement  always  accentuates 
them. 
47 


;:;s 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


Nervous  Symptoms. — Restlessness  of  mind  and  body  is  exceedingly 
characteristic.  The  patient  inclines  to  be  hysterical,  and  weeps  with- 
out provocation;  there  is  insomnia;  tremor,  especially  marked  in  the 
hands,  tongue,  and  lips;  and  various  psychoses  may  develop. 

Metabolism. — In  general  terms,  all  metabolic  activity  is  increased. 
The  skin  is  warm  and  moist;  the  temperature  slightly  raised;  the 
amount  of  urine  increased;  weight  is  lost,  and  in  advanced  stages 
emaciation  may  occur.  Brown  atrophy  of  the  heart  and  degenerations 
of  the  other  viscera  develop  eventually,  and  render  recovery  impossible. 
There  is  great  weariness  quite  early  in  the  disease.  Frequent  attacks 
of  diarrhea  may  occur.  Gastric  indigestion  may  be  a  prominent  symp- 
tom. Capillary  hemorrhages  are  not  infrequent.  The  blood-changes 
are  said  by  Kocher  to  be  characteristic,  and  almost  pathognomonic: 
there  is  slight  leukopenia,  but  marked  increase  in  the  actual  and 
proportional  number  of  lymphocytes,  which  may  outnumber  the  neutro- 
phile  leukocytes;  the  red  blood  cells  and  hemoglobin  remain  unaltered. 


Fig.  812. — Exophthalmic  goiter. 
Duration  seven  years;  twenty-eight 
years  old.  Has  had  seven  children. 
Exophthalmos  not  noticed  by  pa- 
tient.   Episcopal  Hospital. 


Fig.  813.  —  Exophthalmic  goiter.  Goiter 
has  grown  rapidly  during  the  last  year.  No 
tachycardia  or  nervousness.  Same  patient 
as  Fig.  812.     Episcopal  Hospital. 


Exophthalmos  is  not  a  necessary  feature  of  hyperthyroidism.  It 
may  be  present,  and  associated  with  a  goiter,  without  any  of  the  cir- 
culatory, nervous,  or  metabolic  symptoms  which  are  characteristic 
of  the  disease  (Fig.  812).  Its  pathogenesis  is  not  understood.  It  may 
be  absent  when  other  symptoms  of  the  disease  are  very  pronounced. 

Diagnosis. — This  depends  on  recognizing  the  circulatory,  nervous, 
and  metabolic  symptoms  which  have  been  detailed  above;  and  on  the 
blood-changes,  on  which  great  stress  is  laid  by  Kocher.  The  existence 
of  a  palpable  goiter  and  exophthalmos  are  confirmatory  signs,  but  by 
no  means  necessary  for  a  diagnosis.  The  histological  diagnosis,  as 
pointed  out  at  p.  733,  depends  on  the  recognition  of  increase  in  the 
secreting  surface  of  the  gland,  quite  apart  from  other  changes  which 
may  be  present. 


SURGERY  OF  THE  THYROID  GLAND  739 

Prognosis. — Theoretically,  hyperthyroidism  is  a  self-limited  disease; 
but  the  disease  may  kill  the  patient  before  it  burns  itself  out.  In 
rare  cases  the  thyrotoxic  symptoms  subside,  perhaps  aided  by  medical 
treatment,  and  those  of  hypothyroidism  succeed.  The  thyroid  thus 
may  destroy  itself  by  hypersecretion.  But  in  most  cases  the  disease 
grows  progressively  worse.  The  more  acute  its  onset,  the  more  rapid 
is  its  course.  Acute  exacerbations  characterize  some  rather  subacute 
cases.  In  these  and  in  the  hyperacute  cases,  death  may  occur  in  a 
paroxysm,  with  rapid  cardiac  exhaustion  (delirium  cordis),  general 
edema,  albuminuria,  fever,  dyspnea,  etc.  In  other,  more  chronic, 
cases,  death  occurs  from  intercurrent  maladies,  such  as  influenza  or 
tonsillitis;  it  may  occur  merely  from  administration  of  an  anesthetic 
for  operative  purposes,  since  viscera  damaged  by  the  long  continuance 
of  intoxication  cannot  functionate  under  these  additional  demands. 

Treatment. — As  the  disease  is  due  to  intoxication  from  the  thyroid 
gland,  there  are  two  logical  remedies:  one  is  removal  of  part  of  the 
gland,  the  other  is  the  preparation  and  administration  of  an  antitoxic 
serum.  The  latter  has  been  tried  by  Beebe  and  Rogers,  but  not  with 
the  uniform  success  which  has  attended  operative  treatment,  and 
must  be  continued  indefinitely  as  the  cause  of  the  symptoms  is  not 
removed.  In  the  hyperacute  cases  usually  no  treatment  is  of  use, 
and  death  occurs  in  a  short  time.  In  the  subacute  cases,  in  which  the 
thyrotoxic  symptoms  and  the  goiter  appear  simultaneously,  medical 
treatment  should  be  tried  before  resort  to  operation,  as  by  procuring 
absolute  rest  for  mind  and  body  it  is  possible  to  ameliorate  the  patient's 
condition.  In  most  cases  confinement  to  bed  is  imperative,  in  isola- 
tion. Local  cold  is  of  great  value  in  quieting  the  tachycardia.  Kocher 
thinks  iodin  internally  is  of  much  value.  The  bowels  and  kidneys 
must  be  looked  to,  and  a  milk  diet  may  be  beneficial.  Belladonna  or 
atropin,  with  an  occasional  course  of  bromides,  are  useful  in  controlling 
circulatory  disturbances.  If  no  improvement  is  evident  within  a 
couple  of  weeks,  it  is  useless  to  pursue  this  treatment  further,  and 
operation  should  be  undertaken,  as  it  should  even  earlier  if  the  patient 
continues  to  grow  worse,  and  in  the  more  chronic  cases  where  it  may 
be  employed  safely  without  such  careful  preparative  treatment. 

The  Parathyroids. — In  all  operations  injury  of  the  parathyroids 
should  be  avoided;  these  little  glands,  of  uncertain  function,  usually 
are  four  or  more  in  number;  they  are  situated  two  on  each  side  of  the 
neck  behind  the  thyroid  gland,  and  separated  from  it  by  the  posterior 
portion  of  its  capsule.  The  lower  pair  are  in  relation  with  the  terminal 
branches  of  the  inferior  thyroid  artery,  and  are  the  more  constant  in 
position.  The  upper  parathyroids  are  supplied  either  from  the  superior 
thyroid  artery  or  from  communicating  branches  from  the  inferior  thy- 
roid. Removal  or  destruction  of  all  the  parathyroids  is  supposed  to 
be  the  cause  of  post-operative  tetany,  which  has  been  seen  in  a  few 
cases.  As  it  is  impossible  to  identify  the  parathyroids  except  by 
histological  examination  (macroscopically  they  cannot  be  distinguished 
from  lymph  nodes),  the  only  safe  course  is  to  keep  clear  of  the  site 


740  SURGERY  OF   THE  FACE,  MOUTH,  AND  NECK 

where  they  normally  are  found.  This  is  best  done  in  excisions  by 
leaving  the  posterior  portion  of  the  capsule  and,  if  necessary,  a  layer  of 
thyroid  tissue  adherent  to  it. 

Operation. — Tn  severe  cases  it  is  the  custom  first  to  diminish  the 
thyrotoxic  symptoms  by  injecting  boiling  water  (5  to  20  c.c.)  into  several 
parts  of  one  lobe  (M.  F.  Porter,  1915),  or  by  ligating  one  or  more  of  the 
arteries  supplying  the  gland;  and  to  proceed  to  partial  excision  within  a 
week  or  ten  days,  before  the  favorable  effect  of  the  preliminary  opera- 
tion has  passed  away.  Porter's  injections  of  boiling  water  may  be 
repeated  every  other  day  until  the  desired  effect  is  produced.  A  local 
anesthetic  is  used.  In  very  acute  cases  the  patient  will  be  so  much 
worried  and  excited  by  the  anticipation  of  any  operation,  that  Crile 
has  adopted  the  ingenious  plan  of  instituting  a  course  of  very  strict 
pre-operative  treatment,  repeated  every  morning,  and  embodying  the 
essential  steps  in  preparation  for  operation,  as  if  in  themselves  they 
constituted  the  treatment.  Every  morning  the  patient's  neck  is 
washed  as  if  for  operation,  and  dressings  are  applied;  every  morning 
she  inhales  some  essential  oil,  to  simulate  an  anesthetic.  Then  some 
favorable  morning,  in  the  course  of  usual  routine,  a  real  anesthetic  is 
given,  and  the  operation  is  completed  without  the  patient  being  aware 
of  it.  In  Kocher's  hands,  the  mortality  of  operation  in  200  severe  cases 
was  4.5  per  cent.;  and  there  were  85  per  cent,  of  cures.  In  cases  with 
advanced  visceral  degenerations  operation  is  useless. 

Ligation. — Delore  and  Alamartine  (1911)  have  pointed  out  that  the 
circulation  is  best  controlled  if  the  superior  and  inferior  thyroids  on  the 
same  side  are  ligated.  Halsted  (1913)  now  ligates  both  inferior  thyroids. 
The  superior  thyroid  artery  is  exposed  by  a  small  transverse  incision 
over  the  upper  pole  of  the  lateral  lobe,  which  usually  is  palpable 
through  the  skin;  the  sternomastoid  is  drawn  backward  and  the  omo- 
hyoid forward,  and  the  pole  of  the  gland  itself  is  ligated  extracapsularly, 
in  two  places.  This  "polar  ligation,"  introduced  in  1909  by  Jacobson 
and  Stamm,  and  adopted  by  C.  H.  Mayo,  is  valuable  as  it  does  not 
interfere  with  the  blood-supply  to  the  superior  parathyroids,  which 
would  be  jeopardized  if  the  main  trunk  was  ligated;  and  because  it 
controls  the  veins  and  lymphatics  and  also  destroys  most  of  the  vaso- 
dilator nerves  entering  the  lateral  lobe.  This  polar  ligation  thus 
becomes  what  Delore  and  Alamartine  call  an  angeio-neurectomy.  The 
inferior  thyroid  artery  is  best  ligated  at  its  origin  from  the  thyroid  axis, 
since  it  divides  into  numerous  branches  before  entering  the  gland,  and 
separate  ligation  of  these  is  difficult  and  exposes  the  recurrent  laryngeal 
nerve  and  inferior  parathyroid  to  injury.  The  artery  is  exposed  by  an 
incision  parallel  to  the  clavicle  at  the  posterior  border  of  the  sterno- 
mastoid; the  anterior  scalene  muscle  is  identified,  and  the  thyroid  axis 
found  just  to  its  median  border. 

Thyroidectomy. — As  in  the  case  of  simple  goiter  (p.  736)  the  entire 
gland  is  not  removed,  but  only  one  lobe  or  one  lobe  and  half  the 
other.  If  symptoms  persist,  more  gland  tissue  may  be  removed  at  a 
second  operation.  Great  care  in  hemostasis  must  be  exercised,  and 
the  wound  must  be  freely  drained. 


SURGERY  OF  THE  THYMUS  GLAND  741 

Sympathectomy  (Jaboulay,  1896). — Excision  of  both  superior  ganglia 
of  the  cervical  sympathetic,  effective  in  overcoming  the  exophthalmos, 
has  been  abandoned  by  most  surgeons,  because  it  has  very  little  influ- 
ence on  the  other  symptoms. 

Malignant  Tumors  of  the  thyroid  are  not  very  rare,  especially  in 
goitrous  regions.  Carcinoma  is  commoner  than  sarcoma;  endothe- 
lioma also  occurs.  Clinically,  the  distinction  is  not  of  much  impor- 
tance, since,  as  A.  Kocher  says,  "  By  the  time  malignant  goiter  reveals 
its  two  chief  characteristics  it  is  too  late  for  a  radical  cure."  He 
adds  that  if  the  thyroid  continues  to  enlarge  after  puberty,  in  spite 
of  appropriate  internal  treatment,  and  in  the  case  of  any  thyroid  which 
begins  to  grow  without  any  apparent  cause  after  the  thirty-fifth  year 
of  life,  malignant  change  should  be  suspected.  The  two  chief  char- 
acteristics of  these  malignant  tumors  are  irregular  growth,  and  change 
in  consistency.  Instead  of  the  nodules  being  more  or  less  uniform  in 
distribution  and  size,  a  few  of  them  will  begin  to  project  to  an  abnormal 
degree  beyond  the  others,  and  they  will  lose  their  elastic  consistency 
and  become  firmer  and  more  flesh-like.  Pressure  symptoms  occur 
earlier  than  in  benign  enlargement,  because  of  development  of  adhe- 
sions to  surrounding  structures.  Spontaneous  pain  is  not  an  early 
symptom,  but  occurs  in  malignant  growths  much  sooner  than  in 
benign. 

Prognosis. — The  prognosis  is  bad.  Metastasis  occurs  early,  and 
may  be  the  first  evidence  of  malignancy.  In  carcinoma,  and  even 
in  histologically  benign  diffuse  adenoma,  metastasis  to  bones  is 
frequent;  and  Shepherd  has  observed  pulmonary  invasion  by  carci- 
noma through  the  internal  jugular  veins. 

Treatment. — Very  early  extirpation  is  the  only  method  that  offers 
any  hope  of  cure.  Shepherd  says  he  has  completely  excised  over  a 
dozen  thyroids,  and  never  save  in  one  case  (repeated  operations  for 
recurrence)  has  seen  any  evil  effects  attributable  to  injury  of  the  para- 
thyroids though  he  has  taken  no  care  to  preserve  them.  But  the 
prophylactic  administration  of  parathyroidin  is  recommended,  and 
the  use  of  thyroid  extract  may  be  necessary  to  prevent  myxedema. 
Tracheotomy  may  be  necessary  in  far  advanced  inoperable  cases; 
it  may  prove  a  difficult  operation. 

SURGERY  OF  THE  THYMUS  GLAND. 

In  some  infants  acute  or  chronic  dyspnea  is  due  to  enlargement  of 
the  thymus  gland,  which  compresses  the  trachea.  Usually  the  enlarged 
gland  may  be  detected  by  percussion  or  skiagraphy,  and  its  presence 
should  be  suspected  when  tracheotomy  fails  to  relieve  the  dyspnea. 
Then  the  incision  may  be  extended  down  to  the  episternal  notch, 
when  the  thymus  (much  like  an  enlarged  lymph  node)  will  protrude 
from  the  anterior  mediastinum,  and  may  be  drawn  up  into  the  neck. 
So  much  of  it  as  is  easily  detachable  should  be  enucleated  from  its 
capsule  and  removed.    The  wound  should  not  be  drained,  for  drainage 


742  SURGERY  OF  THE  FACE,   MOUTH,  AND  NECK 

implies  infection,  and  this  means  death.  If  the  respiratory  obstruction 
is  relieved  promptly,  recovery  follows.  Olivier  (1912)  studied  the  results 
of  42  thymectomies;  of  the  15  deaths,  7  were  not  due  to  the  operation, 
and  8  were  attributed  to  the  secondary  tracheotomy. 

SURGERY  OF  THE  ESOPHAGUS. 

Foreign  Bodies.— There  are  three  points  at  which  a  foreign  body 
is  apt  to  be  arrested:  (1)  At  the  level  of  the  cricoid  cartilage;  (2) 
where  the  left  bronchus  crosses  the  esophagus;  (3)  at  the  cardiac 
orifice  of  the  stomach.  All  sorts  of  things  may  be  swallowed:  chil- 
dren's playthings,  false  teeth,  pieces  of  bone,  and  in  the  insane,  even 
spoons,  forks,  etc.  Large  bodies  usually  are  arrested  in  the  pharynx, 
and  often  may  be  extracted  with  the  finger.  Bodies  with  sharp  prongs 
may  catch  in  the  esophageal  wall  at  any  point,  and  much  damage  may 
be  done  by  forcible  attempts  at  extraction. 

The  diagnosis  depends  on  the  history,  which  in  infants  and  the  insane 
may  be  very  uncertain;  on  the  presence  of  dysphagia;  and  on  the 
results  of  examination  with  esophageal  instruments  and  the  z-ray. 
It  is  important  to  make  the  diagnosis  as  soon  as  possible,  before  inflam- 
matory softening  or  perforation  of  the  esophageal  wall  occurs.  Do 
not  postpone  thorough  examination  until  the  next  day,  thinking  the 
diagnosis  will  be  easier  then.  It  will  not  be.  The  esophagoscope 
should  be  employed  whenever  available,  and  if  used  early,  before 
the  mucous  secretion  is  excessive,  the  foreign  body  usually  can  be 
seen.  This  is  an  instrument  analogous  to  the  bronchoscope  and 
cystoscope.  It  is  very  much  safer  in  skilled  hands  than  the  insertion 
of  a  bougie,  but  this  may  be  the  only  instrument  obtainable. 

Treatment. — By  means  of  an  esophagoscope  and  the  special  instru- 
ments employed  with  it,  one  skilled  in  the  use  of  such  apparatus 
frequently  will  be  able  to  extract  the  foreign  body  under  the  control 
of  the  eye.  If  this  is  not  possible,  the  surgeon  must  employ  the  older 
and  less  satisfactory  method  of  introducing  an  esophageal  forceps, 
probang,  or  coin-catcher  and  thus  endeavoring  to  remove  the  foreign 
body  by  the  sense  of  touch.  A  general  anesthetic  is  required.  A  coin 
usually  lies  transversely  in  the  esophagus,  and  may  be  caught  by  a 
forceps  whose  blades  open  in  this  direction  (Fig.  814).  If  the  coin 
lies  very  far  down  in  the  esophagus  the  old  fashioned  "coin-catcher" 
(Fig.  815)  may  be  more  useful.  Occasionally  a  lodged  foreign  body 
may  be  advantageously  pushed  on  into  the  stomach.  It  is  not  safe 
to  make  violent  or  too  prolonged  efforts  at  extraction,  especially 
when  more  than  thirty-six  hours  have  elapsed.  When  all  reasonable 
efforts  have  failed,  or  at  once  if  the  nature  of  the  impacted  body 
forbids  attempts  at  extraction  through  the  mouth,  the  surgeon  should 
resort  to  external  esophagotomy  if  the  foreign  body  is  well  above  the 
cardiac  orifice;  if  impacted  at  the  latter  site,  extraction  should  be 
attempted  by  gastrotomy  (p.  928).  Under  the  best  modern  methods 
it  might  be  possible  to  perform  transpleural  esophagotomy. 


SURGERY  OF  THE  ESOPHAGUS 


743 


External  Esoyhagotomy . — Through  an  incision  along  the  anterior 
border  of  the  left  sternomastoid,  with  division  or  downward  dis- 
placement of  the  omohyoid,  the  esophagus  is  exposed  behind  the 
trachea  and  on  the  median  side  of  the  great  vessels  It  should  be  freely 
separated  from  the  surrounding  tissues,  and  incised  on  a  sound  passed 
from  the  mouth,  after  pulling  it  up  into  the  wound  and  isolating  it 
with  gauze.  The  foreign  body  is  then  extracted  with  finger  or  for- 
ceps.   The  incision  in  the  esophagus  is  tightly  sutured  with  at  least 


Fig.  814. — Forceps  for  removing  foreign  bodies  from  the  esophagus. 

two  rows  of  chromic  gut  sutures,  and  a  strip  of  rubber  tissue  is  passed 
down  to  the  site  of  suture,  and  is  not  removed  for  a  week.  The  remain- 
der of  the  wound  is  closed  in  layers.  No  food  should  be  swallowed  for  a 
week  or  ten  days;  rectal  feeding  should  be  employed,  especially  water 
as  in  peritonitis,  but  in  the  case  of  very  weak  patients  liquid  food 
may  be  introduced  by  a  stomach  or  duodenal  tube.  The  prognosis 
is  good  if  the  foreign  body  has  been  removed  within  the  first  thirty- 
six  hours. 


gaesaaa 


Q=^* 


Fig.  815.— 


instruments:  1,  Olive  tipped  bougie;  2,  horse-hair  probang; 
3,  coin-catcher;  4,  esophageal  forceps. 


Stricture  of  the  Esophagus  usually  results  from  lye  burns,  and  is 
especially  frequent  in  small  children  who  drink  a  cupful  of  the  nice 
white  fluid,  mistaking  it  for  milk.  It  may  occur  also  in  adults,  from 
ingestion  of  corrosive  poisons.  Symptoms  of  stricture  may  not  develop 
for  several  months  after  the  accident.  Sometimes  they  appear  rather 
suddenly,  but  usually  there  is  a  gradual  but  progressive  increase  in 
dysphagia,  at  first  for  solids,  then  for  liquids,  and  finally  regurgitation 
occurs  through  the  nostrils  as  soon  as  food  is  swallowed.    In  time  a 


744  SURGERY  OF  THE  FACE,   MOUTH,   AND  NECK 

pouch  may  form,  and  then  regurgitation  may  not  occur  for  half  an 
hour  or  more  after  food  is  ingested.  Any  inflammatory  attack  is  apt 
to  produce  complete  obstruction.  Weight  is  constantly  lost,  and 
emaciation  may  become  extreme.  There  is  a  decided  tendency  to 
bronchial  and  pulmonary  disease,  owing  to  regurgitation  of  decaying 
food,  and  death  may  occur  from  such  intercurrent  malady. 

Diagnosis.  The  diagnosis  is  made  from  the  history  of  the  accident, 
from  the  symptoms,  and  from  examination  of  the  esophagus.  This 
should  be  done  by  the  esophagoscope;  but  if  this  is  not  available, 
an  olive-tipped  bougie  (Fig.  SI 5)  may  be  passed  very  gently  and 
cautiously;  and  the  existence  of  a  stricture  and  its  site  may  be  thus 
determined.  The  .r-ray  will  detect  the  existence  of  a  pouch  if  this 
is  filled  with  an  opaque  meal. 

Treatment. — 1.  If  the  stricture  is  easily  permeable  to  liquid  food, 
it  usually  will  be  possible  to  secure  passage  of  a  bougie,  especially  if 
this  is  done  under  control  of  vision  through  the  esophagoscope. 
Many  strictures  impermeable  to  blind  instrumentation  are  not  imper- 
meable with  esophagoscopy.  The  danger  of  perforation,  especially  if 
there  is  a  thin  walled  pouch,  always  should  be  kept  in  mind.  Such 
an  accident  generally  results  fatally  in  a  few  days  from  septic  pneu- 
monia or  mediastinitis.  If  a  bougie  can  be  passed,  gradual  dilatation 
often  is  possible,  as  in  the  case  of  permeable  urethral  stricture;  but 
hazardous  as  is  the  employment  of  any  force  in  urethral  instrumenta- 
tion, it  is  absolutely  harmless  compared  to  its  use  in  esophageal  work. 
The  safest  esophageal  sound,  when  one  is  used  without  the  esophago- 
scope, is  the  olive-tipped  bougie,  but  it  is  relatively  safe  only  because 
of  its  size.  The  smaller  the  stricture,  the  more  flexible  should  be  the 
instrument.  Gradual  dilatation  may  be  aided  by  internal  esopha- 
gotomy  through  the  esophagoscope,  the  edge  of  the  stricture  being 
divided  under  full  view.  Subsequent  dilatation  always  should  be 
conducted  under  control  of  esophagoscopy. 

2.  If  the  stricture  is  impermeable  to  instruments,  the  treatment 
depends  somewhat  upon  the  amount  of  nourishment  the  patient  can 
take.  If  sufficient  nourishment  is  taken  to  maintain  weight,  various 
expedients  may  be  tried  to  get  through  the  stricture.  The  patient 
may  be  made  to  swallow  a  silver  ball  (Abercrombie,  1830)  or  per- 
forated shot  (Socin,  1889)  attached  to  a  string;  after  resting  on  the 
stricture  for  some  hours  these  may  pass  through,  and  thus  from  day 
to  day  larger  balls  may  be  used,  until  a  bougie  can  be  passed.  These 
methods  are  not  more  effective  than  esophagoscopic  instrumentation, 
but  may  be  tried  when  this  is  not  available.  External  esophagotomy 
rarely  can  be  recommended,  even  when  the  upper  end  of  the  stricture 
is  accessible  through  the  neck.  It  is  not  likely  that  this  method  will 
be  successful  when  esophagoscopy  has  failed,  and  it  cannot  be  known 
that  the  stricture  does  not  extend  all  the  way  down  to  the  cardiac 
orifice.  If  weight  is  being  lost,  it  is  useless  to  postpone  a  resort  to 
gastrostomy  (p.  929).  When  the  stomach  is  opened,  attempts  may 
be  made  to  pass  an  instrument  through  the  stricture  from  below, 


SURGERY  OF  THE  ESOPHAGUS  745 

and  these  occasionally  are  successful.  But  if  the  patient  is  very  weak 
it  is  better  not  to  prolong  the  operation,  but  merely  to  establish  an 
opening  in  the  stomach  as  rapidly  as  possible.  Stamm's  method  is 
the  best  for  these  cases.  It  usually  happens  that  the  stricture  becomes 
permeable  after  the  esophagus  has  had  a  rest  for  some  weeks,  while 
food  is  being  introduced  through  the  gastric  fistula.  This  is  analogous 
to  the  usual  course  of  impermeable  urethral  strictures  after  the  per- 
formance of  Cock's  operation  (p.  1081).  When  the  stricture  becomes 
permeable,  a  string  may  be  passed  through  it  from  the  mouth;  then 
by  extracting  the  other  end  through  the  gastric  fistula,  the  stricture 
may  be  cut  by  a  sawing  motion,  while  the  esophagus  is  kept  taut  to 
prevent  damage  to  its  walls  (Abbe's  method,  1893);  or  the  surgeon 
may  adopt  von  Hacker's  method  (1894)  of  retrograde  dilatation  by 
drawing  through  the  stricture  gradually  increasing  sizes  of  rubber 
tubing,  at  intervals  of  a  few  days  ("Sondierung  ohne  Ende"). 

3.  If  the  stricture  remains  impermeable  even  after  gastrostomy, 
there  are  still  several  plans  of  treatment  which  may  be  adopted. 
Maffei  (1906)  in  two  cases  successfully  exposed  the  esophagus  by  the 
transpleural  route,  and  found  that  the  stricture  became  permeable 
as  soon  as  he  had  released  the  peri-esophageal  adhesions;  the  esophagus 
was  not  opened  at  all.  Roux  (1907)  and  Herzen  (1908)  have  formed 
an  artificial  esophagus  by  transplanting  beneath  the  skin  of  the 
sternum  a  loop  of  the  upper  jejunum,  excluded  from  the  intestinal 
tract.  This  is  to  be  attached  above  to  the  cervical  esophagus,  and 
below  to  the  stomach.  Herzen's  name  for  this  delicate  procedure, 
which  is  completed  in  several  sittings,  is  "ante-thoracic  esophago- 
jejuno-gastrostomy."  Willy  Meyer  (1913)  has  followed  Jianu  and 
Roepke  in  utilizing  a  flap  from  the  greater  curvature  of  the  stomach, 
to  construct  a  new  pre-sternal  esophagus. 

Congenital  Imperforation  of  the  Esophagus  is  a  rare  malformation 
in  which  the  gastric  end  of  the  esophagus  usually  empties  into  a 
bronchus,  and  the  pharyngeal  end  terminates  in  a  blind  pouch.  The 
baby  suffers  from  recurring  attacks  of  suffocation  due  to  regurgi- 
tation of  gastric  contents  into  the  air  passages;  food  swallowed  is  at 
once  regurgitated.  The  best  treatment  is  performance  of  jejunostomy 
(p.  929),  for  the  purpose  of  introducing  nourishment,  as  advised  by 
Demoulin  (1904).  Should  the  infant  survive  (which  is  unusual) 
treatment  as  for  impermeable  stricture  of  the  esophagus  should  be 
attempted  later. 

Diverticula  of  the  Esophagus  may  be  congenital  or  acquired. 
The  acquired  diverticula  are  due  either  to  traction  from  without 
(usually  from  adhesions  to  bronchial  lymph  nodes,  etc.),  or  to  pressure 
from  within.  The  traction  diverticula  rarely  produce  symptoms,  as 
their  lumen  is  oblique  or  horizontal  and  the  orifice  is  directed  down- 
ward (Zenker,  1878);  food  is  not  apt  to  collect  in  them,  and  often 
they  are  found  unexpectedly  at  autopsy.  But  occasionally  during 
life  perforation  occurs.  Pressure  diverticula,  well  studied  by  Halstead 
in  1904,  constantly  produce  symptoms  during  life,  from  accumula- 


746  SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 

tion  and  regurgitation  of  food.  Sometimes  during  meals  a  palpable 
tumor  appears  in  the  left  side  of  the  neck,  and  can  be  emptied  by 
pressure.  Often  the  earlier  part  of  a  meal  will  be  swallowed  more 
easily  than  the  latter  part,  because  gradual  rilling  of  the  pouch  causes 
obstruction  of  the  esophagus.  The  pouch  is  found  most  often  to 
spring  from  the  posterior  wall  of  the  esophagus  in  the  median  line, 
just  below  the  pharynx.  A  bougie  sometimes  will  be  arrested  in  the 
pouch,  and  sometimes  will  pass  on  into  the  stomach,  and  thus  the 
condition  may  simulate  a  spasmodic  stricture.  But  if  one  bougie 
is  arrested  in  the  pouch,  it  may  be  possible  to  pass  another  alongside 
of  it  into  the  stomach.  The  diagnosis  is  aided  by  esophagoscopy  and 
by  the  use  of  the  a>ray  after  filling  the  pouch  with  an  opaque  meal. 

Treatment. — If  the  diverticulum  is  accessible  from  the  neck,  it  should 
be  exposed  from  the  left  side,  and  excised.  The  stump  is  treated  as 
the  appendix  stump  (p.  909),  and  the  wound  treated  as  in  external 
esophagotomy  (p.  743). 

Dilatation  of  the  Esophagus,  as  a  whole,  usually  is  secondary  to 
what  has  been  described  as  cardiospasm,  which  is  now  believed  to  be 
not  a  spastic  condition  of  the  cardiac  orifice  of  the  stomach,  but  of 
the  esophagus  just  above  the  cardia.  The  cause  of  the  "  cardiospasm" 
has  not  always  been  determined,  but  in  some  cases  gross  esophageal 
lesions  (ulcer,  carcinoma,  etc.)  have  been  found. 

Symptoms. — The  symptoms  are  those  of  slowly  oncoming  and  never 
entirely  complete  obstruction  to  food.  In  the  early  stages  there  is 
a  feeling  of  fulness  after  eating,  with  an  uneasy  sensation  in  the 
epigastrium  or  behind  the  sternum;  the  patient  eats  very  slowly, 
and  requires  much  liquid  to  wash  the  food  down;  final  entrance  of 
food  to  the  stomach  may  be  accomplished  only  after  the  patient  has 
retired  to  a  corner  and  urged  the  food  down  by  deep  breathing,  gulp- 
ing, or  curious  contortions  of  the  arms  and  body.  Later,  regurgitation 
occurs  immediately  after  swallowing;  but  when  full  dilatation  has 
developed  food  may  be  retained  for  several  hours.  The  regurgitated 
food  is  not  sour,  as  it  would  be  if  vomited  after  lying  in  the  stomach. 

Diagnosis. — Diagnosis  is  based  on  the  symptoms,  and  on  the  exclu- 
sion of  organic  stricture  by  esophagoscopy  or  by  passage  of  a  bougie. 
A  bougie  may  be  arrested  near  the  cardiac  orifice,  but  usually  passes 
through  after  temporary  arrest.  A  skiagraph,  made  after  ingestion 
of  an  opaque  meal,  also  is  helpful. 

Treatment. — The  most  satisfactory  treatment  is  forcible  divulsion 
of  the  cardia.  This  can  be  done  by  instruments  passed  by  mouth,  as 
in  the  methods  of  Sippy  and  of  Plummer.  The  apparatus  consists 
of  a  rubber  bag  about  10  cm.  long,  encased  in  a  silk  bag  which  limits 
the  possible  distention  to  a  circumference  of  15  cm.  Dilatation  is 
produced  by  an  air-pump.  The  treatment  usually  must  be  repeated 
several  times  before  complete  relief  is  secured.  No  anesthetic  is 
necessary.  In  some  cases  divulsion  of  the  cardia  may  be  done  after 
gastrostomy. 


SURGERY  OF  THE  ESOPHAGUS  747 

Carcinoma. — Carcinoma  is  a  very  frequent  disease  of  the  esoph- 
agus. It  occurs  oftenest  in  males,  in  the  decline  of  life.  About  50 
per  cent,  of  cases  are  near  the  cardia,  40  per  cent,  at  the  bifurcation 
of  the  trachea,  and  only  10  per  cent,  at  the  cricoid  cartilage.  It 
probably  often  develops  in  an  ulcer  or  erosion.  Its  onset  is  insidious, 
but  when  once  symptoms  develop,  they  progress  rapidly.  The  chief 
characteristic  is  increasing  difficulty  in  deglutition,  for  which  no  cause 
can  be  found  in  the  patient's  clinical  history.  Syphilitic  stricture  is 
rare  but  must  be  excluded.  The  diagnosis  from  aortic  aneurysm 
often  is  exceedingly  difficult.  In  carcinoma  very  early  and  great 
enlargement  of  the  bronchial  lymph  nodes  may  occur;  there  often  are 
pressure  palsies  of  the  recurrent  laryngeal  or  sympathetic  nerves;  and 
dyspnea  may  exist.  Referred  pain  is  common,  and  erosion  of  the 
vertebrae  and  even  paraplegia  may  develop  before  symptoms  of 
esophageal  obstruction  are  marked.  Pulmonary  complications  are 
frequent.  Passage  of  a  bougie  may  provoke  hemorrhage.  Esopha- 
goscopy  is  important.  The  prognosis  is  very  bad.  Death  usually 
occurs  in  a  year  from  the  date  of  diagnosis. 

Treatment. — When  thoracic  surgery  becomes  better  developed,  and 
especially  by  the  use  of  anesthesia  by  intratracheal  insufflation,  it  will 
be  possible  to  explore  the  seat  of  disease,  with  the  hope  of  doing 
a  radical  operation.  This  has.  been  accomplished  once  successfully, 
by  Torek  (1913).  In  most  cases  only  the  palliative  operation  of  gas- 
trostomy is  successful,  but  this  should  not  be  employed  so  long  as 
liquids  can  be  swallowed.  Whenever  possible,  before  this  operation 
is  done,  the  intestinal  tract  should  be  cleared  of  the  masses  of  stagnant 
feces  usually  present. 


CHAPTER  XX. 

SURGERY  OF  THE  BREAST,  THE  CHEST  WALL,  THE 
LUNGS,  AND  THE  DIAPHRAGM. 

SURGERY  OF  THE  BREAST. 

Congenital  Anomalies. — The  only  one  of  these  that  is  of  much 
surgical  interest  is  the  existence  of  supernumerary  breasts,  a  con- 
dition known  as  polymastia.  Either  sex  may  be  affected,  but  it  is 
said  to  be  slightly  more  common  in  males.  The  extra  glands  may  be 
situated  almost  in  any  part  of  the  trunk,  most  often  near  the  axilla 
or  groin  (Fig.  81(5),  or  in  a  line  joining  these  two  sites.  The  accessory 
glands  may  be  of  various  sizes.  Sometimes  only  a  supernumerary 
nipple  is  present  {polythelia)  (Fig.  817),  and  sometimes  a  mass  of 
mammary  tissue  without  a  nipple  exists  in  the  subcutaneous  tissues. 
In  men  this  resembles  a  lipoma;  but  in  women  its  true  nature  is 
revealed  by  its  increase  in  size  during  menstruation,  or  pregnancy, 
or  lactation.  Any  supernumerary  mamma  which  causes  annoyance 
should  be  excised. 


Fig.  816. — Supernumerary  mamma  (or  lipoma?)  in  adult  male.  Since  puberty  has 
had  this  mass  which  at  times  used  to  discharge  a  little  whitish  fluid,  Note  the  nipple- 
like projection,  but  absence  of  pigmentation.    Episcopal  Hospital. 

Affections  of  the  Nipple. — Sometimes  a  nipple  fails  to  develop 
properly,  especially  where  tight  underclothing  is  constantly  worn. 
During  pregnancy  care  should  be  taken  to  favor  its  development 
by  drawing  it  out,  gently;  and  it  should  be  further  prepared  for 
suckling  by  frequent  cleansing  and  application  of  astringent  washes, 
of  which  none  is  better  than  dilute  alcohol.  During  lactation, 
(748) 


TREATMENT  OF  ACUTE  MASTITIS 


749 


not  only  should  the  condition  of  the  infant's  mouth  be  watched, 
but  the  nipple  should  be  washed  with  warm  water  and  castile  soap 
before  and  after  suckling,  and  if  any  tendency  to  irritation  exists 
it  should  be  dusted  with  boric  acid  or  borated  talcum  powder  after 
cleansing  after  each  act  of  nursing.  Fissures  and  excoriations  of  the 
nipple,  which  are  extremely  painful  and  interfere  with  suckling, 
should  be  treated  by  unremit- 
ting attention  to  cleanliness. 
The  use  of  a  nipple  shield  or 
breast  pump,  so  as  to  prevent 
direct  contact  of  the  child's 
mouth,  is  necessary,  and  in 
most  cases  the  act  of  suckling 
must  be  discontinued  tempor- 
arily. The  excoriations  and 
fissures,  after  gentle  cleansing, 
should  be  painted  with  tinc- 
ture of  iodin  or  a  weak  glyce- 
rite  of  tannin,  and  then  dusted 
with  boric  acid  powder.  The 
use  of  ointments  is  injurious. 

Acute  Mastitis. — Though  in- 
flammation of  the  breast  occa- 
sonally  develops  in  the  newborn, 
and  in  boys  and  girls  at  puberty, 
it   occurs    oftenest    in   nursing 

women,  being  in  most  cases  an  ascending  infection  from  the  nipple  by 
way  of  the  ducts  or  the  lymphatics.  It  is  most  frequent  in  primipara3, 
especially  in  those  with  poorly  developed  nipples,  which  have  received 
insufficient  attention  during  pregnancy.  It  occurs  most  often  within 
a  few  days  of  delivery,  or  not  until  the  end  of  lactation. 

Acute  mastitis  is  characterized  by  the  usual  signs  of  inflammation, 
which  are  confined  in  almost  all  instances  to  one  or  more  lobes  of  the 
gland.  Diffuse  inflammation  is  rare.  The  regions  affected  feel 
tough  and  doughy,  and  tenderness  is  not  very  marked.  The  skin  is 
unaltered  and  moves  freely  over  the  breast.  There  is  a  heavy  feel- 
ing, with  dull  pain,  and  occasionally  shooting  pains.  In  a  puerperal 
woman  this  stage  is  described  as  "caked  breast,"  because  of  the  accu- 
mulation and  inspissation  of  the  milk  owing  to  obstruction  of  the 
galactophorous  ducts  by  the  inflammatory  changes. 

Treatment. — Treatment  consists  in  attention  to  the  nipple,  which 
may  be  fissured  or  excoriated,  and  to  the  patient's  general  health. 
The  child  should  not  be  allowed  to  suckle  from  the  affected  breast 
until  resolution  is  complete.  Daily  light  massage  of  the  area  affected 
usually  is  efficacious  in  overcoming  the  stagnation  and  promoting 
resolution  without  suppuration.  Some  ointment  with  lanolin  as 
a  basis  should  be  used  in  connection  with  the  massage.  In  the 
intervals  the  breast  should  be  covered  with  belladonna  and  mercury  or 


Fig.  817. — Polythelia;  a  supernumerary 
nipple  near  right  nipple.  Orthopedic  Hos- 
pital. 


750 


SURGERY  OF  THE  BREAST 


other  sorbcfacient  ointment,  and  well  supported  with  a  compressory 
bandage  or  binder.  Meantime  a  breast  pump  must  be  employed. 
Another  valuable  aid  in  resolution  is  passive  hyperemia,  according 
to  Bier's  method,  with  a  cupping  glass  applied  over  the  nipple,  as 
originally  introduced  by  Chassaignac. 

Mammary  Abscess.  Mammary  abscess  usually  develops  as  a 
sequel  of  stagnation  mastitis  (caked  breast).  The  area  affected 
becomes  more  tender;  dusky  redness  appears  in  the  skin;  this  becomes 
adherent  to  the  deeper  structures;  and  the  abscess  is  ready  to  be 
opened  (Fig.  818).     Before  this  occurs,  however,  destruction  of  the 

mammary  tissue  may  be  very 
extensive,  and  it  is  very  im- 
portant to  recognize  the  onset 
of  suppuration  as  early  as  pos- 
sible. The  fluid  expressed  from 
the  nipple  by  massage,  in  the 
stage  of  caked  breast,  should  be 
collected  from  time  to  time  on 
gauze.  The  milk  will  be  ab- 
sorbed; but  if  there  is  any  pus 
in  the  fluid,  it  will  remain  on 
the  surface  of  the  gauze  and 
stain  it  yellow.  This  is  known 
as  Budin's  sign.  As  soon  as 
suppuration  is  suspected,  the 
inflamed  area  should  be  incised. 
This  incision  should  be  made 
directly  over  the  area  affected, 
and  in  a  line  radiating  from 
the  nipple,  so  as  to  injure  as 
few  of  the  milk  ducts  as  possible 
and  thus  decrease  the  chance  of  a 
lacteal  fistula  developing.  The  earlier  and  more  freely  this  incision 
is  made,  the  less  danger  there  is  of  the  pus  burrowing  among  the 
glandular  tissue.  If  delayed,  various  pockets  of  pus  will  be  found, 
and  these  will  have  to  be  broken  open  to  ensure  free  drainage.  Tube 
drainage  is  desirable  until  the  discharge  of  pus  ceases.  An  abundant 
dressing  of  hot  moist  gauze  (soaked  in  boric  acid  or  normal  saline 
solution)  is  required  to  absorb  the  discharge.  After  drainage  is  dis- 
continued the  wound  closes  rapidly  in  most  cases,  if  incision  has  been 
made  early  enough;  if  it  has  been  delayed  or  not  sufficiently  free,  second- 
ary abscesses  may  form.  Very  rarely,  when  the  breast  is  riddled  with 
abscesses  and  discharging  sinuses,  amputation  is  required. 

Chronic  mammary  abscess  is  not  very  rare;  it  may  be  subacute  or 
frankly  chronic.  The  former  usually  arises  during  lactation,  as  the 
result  of  an  unresolved  stagnation  mastitis;  or  after  an  imperfectly 
drained  acute  abscess.  Those  which  develop  independently  of 
lactation  are  much  more  unusual,  and  may  be  due  to  suppuration  in 


Fig.  818. — Abscess  of  left  breast  in 
primipara.  Age  twenty  years,  nursing 
baby  three  months  old.  Duration 
mastitis  ten  days.  Incised  and  drained  by 
tube;  in  nine  days  only  a  granulating  sur- 
face remained.    Episcopal  Hospital. 


of 


CHRONIC  MASTITIS  751 

a  hematoma  (from  trauma),  or  to  excoriations,  patches  of  eczema, 
etc.,  on  the  nipple  or  in  the  inframammary  fold.  The  symptoms  are 
those  of  chronic  mastitis  (see  below),  but  the  physical  signs  resemble 
more  those  of  a  neoplasm  (p.  759),  and  the  diagnosis,  which  often  is 
impossible,  rests  on  the  history  of  the  case,  and  the  detection  of  some 
source  of  infection.  Treatment:  Exploratory  incision,  best  by  the 
submammary  incision  (p.  760),  usually  is  necessary  for  diagnosis; 
and  the  abscess  wall  which  often  is  thick  and  indurated,  should  then 
be  removed  in  entirety. 

Submammary  Abscess. — Suppuration  may  occur  in  the  cellular 
tissue  between  the  pectoral  muscle  and  the  breast.  Usually  this  is 
caused  by  an  abscess  in  a  deep  lying  lobe  of  the  mammary  gland, 
where  pointing  occurs  through  the  deep  layer  of  superficial  fascia 
in  which  the  gland  lies,  instead  of  through  the  overlying  skin;  indeed, 
prolongations  of  the  gland  may  extend  normally  into  the  retro- 
mammary space.  In  a  few  cases,  however,  submammary  abscess  is 
secondary  to  axillary  lymphadenitis  or  to  diseases  of  the  pleura, 
caries  of  the  ribs,  etc.,  which  usually  are  tuberculous  in  nature.  The 
diagnosis  of  submammary  abscess  is  not  always  easy;  the  gland  is 
prominent,  raised  away  from  the  chest  by  the  suppuration  beneath; 
but  owing  to  the  deep  seat  of  the  suppuration  the  ordinary  physical 
signs  of  an  abscess  may  not  be  present.  The  abscess  may  simulate 
a  small  hard  tumor,  especially  as  axillary  adenitis  often  is  present. 
Treatment  consists  in  evacuation  of  the  pus  by  a  curved  incision 
beneath  the  breast,  with  free  drainage  until  the  discharge  ceases. 

Subpectoral  Abscess. — See  p.  778. 

Chronic  Mastitis. — In  addition  to  the  acute  infectious  mastitis, 
already  described  as  most  frequent  in  puerperal  women,  there  occurs 
a  form  of  circumscribed  subacute  or  chronic  mastitis,  probably  also 
infectious  in  origin,  in  women  at  almost  any  age,  but  usually  in  those 
between  twenty  and  thirty,  or  in  those  approaching  the  menopause, 
and  among  the  unmarried  nearly  as  frequently  as  in  those  who  have 
borne  children.  They  come  to  the  surgeon  complaining  of  a  painful 
and  tender  area  in  the  breast,  about  which  they  not  infrequently 
seem  unduly  alarmed.  Examination  shows  slight  or  no  enlargement 
of  the  breast,  and  palpation  of  the  gland  with  the  hand,  pressing  it 
flat  against  the  chest  wall,  makes  it  clear  that  there  is  no  tumor 
present.  If  the  gland  is  examined  between  the  thumb  and  fingers, 
one  or  more  irregularly-shaped,  ill  defined  masses  may  be  felt;  these 
usually  seem  to  radiate  from  the  nipple,  and  undoubtedly  are  in  the 
glandular  tissue.  The  overlying  skin  is  unaltered,  and  the  breast 
moves  freely  upon  the  chest  wall.  The  mass  may  be  exquisitely 
tender,  and  the  seat  of  shooting  or  neuralgic  pains.  The  overlying 
skin  may  be  highly  hyperesthetic.  To  such  a  condition  in  neurotic 
women,  the  term  mastodynia  or  neuralgia  of  the  breast  has  been  applied. 
This  is  the  "irritable  tumor  of  the  breast"  of  Sir  Astley  Cooper  (1829), 
though  it  is  also  possible  that  such  a  condition  might  be  caused  by  a 
false  neuroma  (p.  320)  as  in  other  portions  of  the  body.    Pain  referred 


752  SURGERY  OF  THE  BREAST 

to  the  breast  in  cases  of  intercostal  neuralgia  should  not  be  confused 
with  true  mastodynia.  ///  most  cases  of  mastodynia  both  breasts  are 
affected,  but  only  one  out  of  a  number  of  such  lumps  may  give 
symptoms.  They  may  produce  symptoms  during  menstruation  or 
pregnancy,  and  not  at  other  times. 

The  cause  of  these  changes  is  obscure,  and  the  subject  is  not  much 
clarified  by  the  various  hypotheses  which  have  been  advanced.  If 
the  woman  has  borne  children,  the  natural  assumption  is  that  these 
masses  are  the  result  of  changes  occurring  during  lactation;  they  may 
be  the  remains  of  an  area  of  stagnation  mastitis  (caked  breast)  wbjch 
was  so  slight  as  to  have  been  overlooked  at  the  time.  In  virgins, 
it  may  be  assumed  that  the  breast  has  been  subject  to  forgotten 
trauma;  or  that  its  condition  is  connected  with  some  functional 
derangement  of  the  pelvic  organs. 

The  pathological  anatomy  of  the  condition  is  practically  unknown, 
as  operation  has  been  undertaken  very  seldom.  Lecene  (1911) 
examined  a  fragment  of  tissue  from  such  a  specimen,  and  found 
lesions  which  corresponded  to  a  functional  hypertrophy  of  the  acini, 
with  lymphatic  stasis,  and  slight  degree  of  congestion;  he  concluded 
that  they  wrere  trophic  or  vasomotor  in  origin,  and  in  no  way  truly 
inflammatory. 

The  clinical  course  of  the  disease  is  various.  Usually  the  symptoms 
subside  under  conservative  treatment,  and  the  masses  do  not  enlarge 
or  give  any  other  evidence  of  their  presence;  in  many  cases  they 
almost  disappear.  In  some  cases,  however,  a  cystic  transformation 
supervenes,  the  pathogenesis  of  which  is  uncertain;  probably  it  is 
neoplastic  in  character,  and  not  due  to  inflammatory  compression 
of  the  gland  ducts  (p.  749). 

Treatment. — Firm  support,  by  bandaging  or  binder,  or  even  by 
adhesive  plaster  strapping,  should  be  provided,  unless  the  tenderness 
is  so  excessive  as  to  render  this  impossible.  Belladonna  and  mercury, 
compound  iodin  or  ichthyol  ointment,  applied  to  the  breast,  leaving 
the  nipple  uncovered,  is  useful  in  relieving  tenderness.  When  tender- 
ness subsides,  gentle  massage  should  be  given.  The  condition  of  the 
pelvic  organs  should  be  determined,  and  suitable  treatment  insti- 
tuted. Tonics,  good  food,  and  general  hygienic  measures  should  not 
be  neglected. 

In  addition  to  this  circumscribed  form  of  chronic  mastitis,  some 
writers  recognize  a  diffuse  chronic  mastitis.  This  subject  is  discussed 
at  p.  7 .">('). 

Galactocele. — Closely  related  pathologically  with  chronic  mastitis 
is  the  condition  described  as  galactocele,  formerly  considered  a 
retention  cyst  of  the  breast.  The  cyst  wall,  however,  is  not  composed 
of  secreting  cells,  but  is  formed  by  a  condensation  of  surrounding 
connective  tissues.  Lecene  (1911)  holds  that  it  is  merely  a  chronic 
abscess  into  wrhich  milk  ducts  have  opened  secondarily;  others,  with 
less  probability  as  it  seems  to  me,  contend  that  the  primary  con- 
dition was  dilatation  of    the  lactiferous  tubules,  and  that  the  cyst 


SYPHILIS  753 

is  formed  by  their  rupture  into  the  surrounding  tissues.  Galactocele 
is  quite  rare,  and  occurs  most  often  during  lactation.  A  small  lump 
forms  quite  suddenly;  usually  it  is  in  the  region  of  the  areola,  but 
may  be  more  deeply  seated.  Sometimes  several  cysts  exist.  The 
mass  is  not  tender  or  painful,  feels  semi-cystic,  and  is  quite  movable 
beneath  the  skin  and  on  the  underlying  pectoral  fascia.  In  many 
cases  pressure  on  the  swelling  causes  milk  to  exude  from  the  nipple, 
and  the  cyst  may  thus  be  emptied.  In  other  cases  its  contents  become 
inspissated,  and  resemble  butter  or  cheese,  when  there  may  be  pitting 
on  pressure,  which  is  a  very  characteristic  sign.  Lacteal  calculi  have 
been  described  in  some  of  these  cases,  but  modern  writers  consider 
the  reports  apocryphal. 

Treatment. — A  galactocele  should  be  excised,  and  the  wound 
sutured.  Incision,  followed  by  packing,  is  followed  by  tedious  cure, 
and  the  cicatrix  is  more  conspicuous. 

Tuberculosis  of  the  Breast  is  a  rare  affection.  Deaver  and  McFar- 
land  (1917)  refer  to  90  cases.  It  occurs  almost  solely  in  women  from 
thirty  to  fifty  years  of  age,  usually  those  who  have  borne  children. 
The  infection  may  be  an  ascending  one  from  the  nipple,  by  way  of  the 
ducts  or  lymphatics;  may  be  hematogenous;  or  may  arise  by  extension 
from  an  adjacent  focus  in  the  ribs,  submammary  lymphatics,  or  pleura. 
Many  scattered  nodules  may  be  found,  or  one  or  two  large  masses. 
The  tendency  toward  the  formation  of  cold  abscess  and  toward  spon- 
taneous fistulization  is  more  common  in  the  latter  form.  Until  this 
stage  is  reached  the  diagnosis  is  nearly  impossible  clinically,  and  even 
after  these  developments  it  is  not  always  easy.  The  axillary  lymphatics 
usually  are  enlarged.  If  secondary  infection  follows  fistulization,  the 
general  health  rapidly  deteriorates. 

Treatment. — The  only  satisfactory  treatment  is  amputation  of 
the  breast,  and  extirpation  of  the  axillary  lymphatics.  The  operation 
resembles  that  for  carcinoma,  but  it  is  not  necessary  to  remove  the 
pectoral  muscles  unless  they  are  manifestly  diseased. 

Syphilis. — Syphilis  may  affect  the  skin  over  the  breast,  or  the 
mammary  gland  itself.  A  chancre  presents  the  same  characters 
here  as  elsewhere;  it  occurs  almost  exclusively  in  women  who  act  as 
wet-nurses  to  foundlings  or  other  infants  with  congenital  syphilis; 
the  lesions  may  be  multiple  and  often  both  breasts  are  affected. 
Prophylaxis  usually  is  possible,  and  a  syphilitic  child  never  should 
be  nursed  by  another  than  its  own  mother,  who  is  immune  to  infection 
in  this  way,  according  to  Colles'slaw  (p.  1053).  Secondary  lesions  of 
syphilis,  especially  mucous  patches,  often  may  be  found  in  the  sub- 
mammary fold  when  not  visible  elsewhere.  Sometimes  in  this  stage 
of  syphilis  the  mammary  glands  become  swollen  and  painful,  the 
condition  being  known  as  diffuse  syphilitic  mastitis.  Gumma  is  the 
most  frequent  lesion  of  syphilis  which  affects  the  glandular  tissue 
of  the  breast.  It  is  quite  rare,  however,  and  is  difficult  to  distinguish 
from  some  benign  tumors  unless  a  distinct  history  of  syphilis  can 
be  obtained,  or  the  Wassermann  test  is  positive,  or  when  the  bene- 

48 


754 


SURGERY  OF  THE  BREAST 


ficial  effect  of  antisyphilitic  treatment  becomes  apparent.  Fortunately 
the  iodides  are  very  rapidly  curative. 

Tumors  of  the  Breast. — The  subject  of  tumors  of  the  mammary 
gland  usually  is  a  difficult  one  for  the  student,  because  owing  to  the 
complexity  of  its  structure  the  tumors  growing  in  it  are  of  many 
different  kinds  derived  from  epithelial  or  fibrous  tissues.  Thus 
there  may  be  adenomatous,  papillomatous,  epitheliomatous,  cystic, 
and  even  sarcomatous  tumors.  And  as  in  most  of  these  tumors  both 
the  epithelial  and  fibrous  elements  seem  to  participate  almost  equally 
in  the  blastomatous  transformation,  it  is  rare  for  a  pure  adenoma, 
or  a  pure  fibroma  to  develop.  Instead  we  find  many  combinations 
of  fibrous,  adenomatous,  cystic,  papillomatous,  and  other  conditions. 
The  following  classification,  based  in  part  on  that  of  J.  Collins  Warren 
(1905),  seems  to  me  the  most  satisfactory.  The  relative  frequency 
of  the  different  growths  is  indicated  by  the  attached  percentages. 


Blastomatoid  Conditions 

(a)  Fibro-adenomatosis,      .  2  per  cent. 

(b)  Cyst-adenomatosis,   15.8  per  cent. 

Benign  Tumors 

1 .  Fibro-adenoma,  9 . 6  per  cent. 

/  \  -n    -j     x  i  cu  /  Intracanalicular 

(a)  Periductal  fibroma  j  Pericanalicuiar 

(b)  Periductal  myxoma 

(c)  Periductal  sarcoma 

2.  CVst-adenoma,  2.4  per  cent. 

(a)  Fibro-cystadenoma 

(b)  Papillary-cystadenoma 
Simple  Adenoma 


16  per  cent. 


4.  Lipoma 

5.  Angeioma 

6.  Endothelioma 

7.  Enchondroma 


1  per  cent. 


12  per  cent. 


Malignant  Tumors 

1.  Sarcoma,         1  per  cent. 

2.  Carcinoma,  70  per  cent, 
(a)  Adenocarcinoma 

Solid-celled  Carcinoma 

1.  Scirrhous  Carcinoma 

2.  Carcinoma  Simplex 

3.  Medullary  Carcinoma 
Paget's  Disease  of  the  Nipple 
Carcinomatous  Cyst 


(6) 


(c) 

(d) 


71  per  cent. 


Before  discussing  blastomas,  or  tumors  proper,  it  is  necessary  to 
say  something  of  certain  blastomatoid  conditions  which  occur  in  the 
breast.  The  general  characters  of  these  conditions  were  discussed 
in  Chapter  IV. 

In  the  mammary  gland  there  occur  lesions  the  true  nature  of  which 
is  still  in  much  dispute.  As  to  one  condition  especially,  while  it  may 
be  said  that  surgeons  acknowledge  its  existence  and  are  agreed  on 
its  clinical  features;  and  while  pathologists  agree  on  the  histological 
picture;  yet  the  former  cannot  agree  on  a  name  which  they  consider 


TUMORS  OF  THE  BREAST  755 

descriptive,  and  the  latter  cannot  agree  on  the  interpretation  of 
what  they  see  under  the  microscope.  This  condition  is  known  in 
some  quarters  by  the  name  "chronic  cystic  mastitis."  Another 
condition  the  classification  of  which  is  disputed,  is  described  as 
"idiopathic  hypertrophy"  of  the  breasts.  Now  when  one  looks  at 
the  classification  of  tumors  given  above,  he  sees  that  under  the  benign 
growths  the  two  main  types,  which  are  fibro-epithelial  in  character, 
are  (1)  Fibro-adenoma,  and  (2)  Cystadenoma.  Were  he  to  look 
around  for  blastomatoid  conditions  in  his  patients  corresponding 
to  these  tumors,  he  would  find  that  such  conditions  actually  occur; 
and  it  would  be  a  matter  of  surprise  that  no  one  had  previously 
recognized  that  idiopathic  hypertrophy  of  the  breasts  corresponds 
to  a  fibro-adenomatosis,  and  that  chronic  cystic  mastitis  corresponds 
to  a  cystadenomatosis.  Let  us  look  then  at  these  two  conditions 
more  narrowly,  and  see  what  they  are: 

Fibro-adenomatosis. — Diffuse  or  "idiopathic  hypertrophy"  of  the 
breasts  may  appear  first  during  pregnancy;  but  the  disease  in  most 
cases  affects  virgins  soon  after  the  age  of  puberty.  Albert  (1910) 
collected  18  cases  of  the  former  and  52  of  the  latter  variety.  It  is 
doubtful  whether  the  conditions  are  pathologically  the  same:  in 
the  cases  which  develop  during  pregnancy  the  glandular  elements 
are  markedly  increased,  whereas  in  the  virginal  form  it  is  a  pure 
fibromatous  over-growth,  the  undeveloped  glandular  elements  being 
practically  unchanged.  This  difference  may  be  due  merely  to  the 
undeveloped  condition  of  the  virgin  breast. 

Both  breasts  are  enlarged  in  almost  all  cases  (62  out  of  70  cases 
collected  by  Albert),  and  they  may  reach  an  immense  size.  In  Durs- 
ton's  historic  case,  recorded  in  1669,  the  weight  of  one  breast,  removed 
postmortem,  was  64  pounds.  Seldom,  however,  does  the  weight 
exceed  8  to  12  pounds.  There  are  no  symptoms  other  than  dis- 
comfort from  the  size  and  weight,  but  the  breasts  may  increase 
and  decrease  slightly  in  size  from  time  to  time.  The  form  which 
arises  during  pregnancy  sometimes  subsides  spontaneously  when  the 
pregnancy  and  lactation  are  ended;  but  the  virginal  form  progres- 
sively increases.  The  growth  is  slow,  and  the  disease  extends  over 
many  years.  Very  rapid  enlargement  of  one  breast  alone,  though 
it  bear  the  character  of  a  simple  hypertrophy,  always  should  rouse 
suspicion  of  malignancy,  especially  sarcoma. 

Treatment. — Treatment  of  the  condition  which  arises  during  preg- 
nancy always  should  be  palliative;  this  consists  in  the  recumbent 
position,  with  elevation  and  compression  of  the  breasts;  the  use  of 
sorbefacient  ointments  locally;  the  internal  administration  of  potas- 
sium iodide  or  thyroid  extract;  repeated  catharsis,  and  a  dry  diet.  If 
no  improvement  is  noted  after  pregnancy  has  terminated,  and  in  the 
virginal  cases  as  soon  as  the  diagnosis  is  assured,  one  of  the  breasts 
should  be  amputated.  In  a  few  cases  the  remaining  breast  has  then 
somewhat  decreased  in  size.  If  it  does  not,  it  should  be  removed 
subsequently. 


750  SURGERY  OF  THE  BREAST 

Cystadenomatosis  or  Abnormal  Involution  of  the  Breast. — In  1883 
Reclus  described  in  detail  a  "cystic  disease  of  the  breast,"  which 
he  had  studied  first  over  twenty  years  before,  and  which  had  been 
recognized  by  F.  Konig  (1875),  by  Brodie  (1840),  and  by  Sir  Astley 
( looper  (1829).  In  more  recent  times  it  has  been  studied  by  Schimmel- 
busch  (1890),  who  named  it  cystadenoma;  by  Konig  (1893),  who 
called  it  mastitis  chronica  cystica;  by  J.  C.  Warren  (1905),  for  whom 
it  was  an  abnormal  involution  of  the  breast;  and  by  Bloodgood  (1900), 
who  called  it  senile  parenchymatous  hypertrophy.  These  are  only  a 
few  of  the  names  by  which  it  is  known.  It  matters  little  by  what 
name  it  is  called,  so  long  as  people  understand  what  is  referred  to; 
and  I  have  not  had  the  temerity  to  select  a  new  name  for  it,  but  have 
followed  Warren,  who  restored  it  to  the  position  in  the  nosology 
of  breast  lesions  to  which  it  wTas  originally  assigned  by  Sir  Astley 
Cooper:  a  pathological  change  similar  in  nature  to  that  of  diffuse 
virginal  "hypertrophy,"  though  characterized  by  epithelial  (cystic) 
growth,  where  the  latter  is  characterized  by  fibrous. 

The  disease  is  very  frequent,  but  may  exist  for  years  without 
producing  symptoms  Though  seen  oftenest  in  women  from  thirty 
to  fifty  years  of  age,  this  is  no  proof  that  it  has  not  had  an  obscure 
beginning  at  a  much  earlier  age.  Occasionally  it  comes  under  obser- 
vation shortly  after  puberty,  when  the  mammary  glands  begin  to 
develop;  but  is  much  more  frequently  seen  when  their  functional 
activity  is  drawing  to  a  close.  It  is  rare  after  the  menopause.  In 
most  cases  both  breasts  are  diseased,  though  only  one  may  produce 
symptoms.  The  disease  appears  to  be  as  common  in  the  unmarried 
and  in  those  who  have  borne  no  children  as  in  those  in  whom  the 
mammary  glands  have  been  functionally  active. 

Symptoms  and  Clinical  Course. — The  woman  consults  a  physician 
usually  because  she  has  an  uncomfortable  feeling  in  the  breast,  and 
perhaps  because  she  has  noticed  that  it  has  growm  larger,  or  because 
by  accident  she  has  felt  a  lump  in  it.  On  examination  the  breast 
generally  is  found  enlarged,  but  not  unduly  pendulous.  No  lump  or 
tumor  is  visible.  If  the  gland  is  picked  up  in  the  thumb  and  fingers, 
it  may  seem  that  there  is  a  considerable  tumor  in  it,  but  if  the  hand 
presses  the  gland  flat  against  the  chest  it  is  evident  that  there  is  no 
tumor  at  all.  There  should  now  be  undertaken  what  Astley  Cooper 
calls  a  very  careful  and  nice  manipular  examination.  What  is  detected 
is  very  characteristic:  seemingly  each  individual  lobule  can  be  felt 
distinctly,  enlarged  and  hardened,  and  moving  freely  upon  the  other 
lobules.  The  breast  feels  as  if  it  were  full  of  lead  shot,  varying  in 
size  from  pin-head  to  grape-size.  Early  in  the  disease  no  large  masses 
are  felt.  These  little,  hard  masses  are  mostly  in  the  center  of  the 
gland,  beneath  the  nipple  and  areola.  Pressure  on  the  breast  causes 
no  pain,  but  an  occasional  shooting  pain  occurs.  The  overlying 
skin  is  normal.  There  is  no  discharge  from  the  nipple.  The  axillary 
nodes  are  not  palpable.  If  now  the  other  breast  be  examined,  almost 
invariably  a  similar  condition,  perhaps  not  so  pronounced,  will  be 
found  in  it. 


CYST  ADENOMATOSIS  757 

If  such  a  breast  is  amputated,  it  is  found  that  the  shot-like  particles 
which  felt  so  hard,  and  which  were  distributed  through  all  parts  of 
the  gland,  are  not  solid  at  all,  as  one  might  imagine;  they  are  minute 
cysts,  tensely  filled  with  clear  or  slightly  yellow  or  even  brownish 
fluid.  The  cyst  walls  are  smooth;  there  are  no  intracystic  growths. 
Microscopical  examination  shows  that  the  cysts  are  lined  with  gland- 
ular epithelium,  which  shows  little  if  any  tendency  to  proliferation 
beyond  the  capacity  of  the  basement  membrane ;  seldom  in  any  place 
is  there  more  than  one  row  of  cells  on  the  basement  membrane,  and 
never  is  there  any  papillomatous  out-growth  into  the  cavity  of  the 
cyst.  The  stroma  of  the  breast  is  a  dense  white  mass  of  fibrous 
tissue,  and  there  is  no  single  area  in  the  entire  breast  which  can  be 
said  to  be  free  of  disease.  The  change  is  not  one  of  tumor  formation, 
but  a  general  blastomatoid  over-growth. 

If  no  treatment  is  instituted  the  disease  may  progress;  or  after  a 
few  years,  a  secondary  atrophy  may  set  in,  the  breast  decreasing  in 
size,  all  symptoms  subsiding,  and  the  patient  remaining  well.  This, 
however,  is  rare;  in  most  cases  the  disease  is  progressive.  In  one 
portion  of  the  breast  a  larger,  more  clearly  outlined  mass  may  be  felt, 
and  sometimes  there  are  two  or  three  such  masses.  They  may  be 
visible  as  rounded  projections  beneath  the  skin.  When  very  large 
they  may  give  a  sense  of  fluctuation.  They  are  cysts;  and  have 
formed  by  the  gradual  distention  of  one  or  more  of  the  small  cysts 
which  have  been  present  for  years.  In  other  parts  of  the  breast  these 
small  cysts  may  still  be  felt  on  "nice  manipular  examination."  At 
this  latter  stage  of  the  disease,  there  sometimes  is  a  glairy  or  clear 
yellowish  discharge  from  the  nipple;  pressure  on  the  cysts  may  cause 
this  fluid  to  appear.  The  cysts  may  oscillate  in  size  from  month  to 
month,  and  at  times  the  axillary  lymph  nodes  may  become  palpable, 
and  again  this  swelling  may  subside.  Pathological  examination  at 
this  stage  may  show  the  cysts  still  simple  in  nature,  with  smooth 
lining  wall,  but  in  the  vast  majority  of  cases  the  cysts,  at  least  the 
larger  ones,  contain  intracystic  papillomatous  out-growths. 

If  still  no  treatment  is  instituted,  some  of  the  clinical  characteristics 
of  malignancy  may  be  noted.  The  nipple  may  seem  retracted  into 
the  gland,  but  usually  can  be  drawn  out  easily;  the  skin  may  become 
adherent,  not  by  cellular  infiltration,  but  by  condensation  of  the 
intervening  tissues;  and  at  last  one  of  the  cysts  may  grow  so  large  as 
to  cause  pressure  necrosis  of  the  overlying  skin.  The  contents  of  the 
cyst  will  then  be  discharged,  and  the  cyst,  if  it  contains  no  papillo- 
matous out-growths,  may  collapse,  and  in  rare  cases  healing  may 
occur.  If  the  cyst  contains  papillomatous  out-growths,  these  may 
protrude  through  the  opening  formed  in  the  skin  by  sloughing, 
and  a  fungus  growth  will  develop  which  it  may  be  very  difficult  to 
distinguish  from  a  malignant  tumor.  At  the  present  day,  however, 
it  is  almost  an  unknown  thing  for  the  disease  to  be  allowed  to 
reach  this  advanced  stage,  as  the  breast  is  removed  at  an  earlier 
period. 


75S  SURGERY  OF  THE  BREAST 

Another,  and  probably  more  frequent  contingency  may  arise. 
Instead  of  the  disease  taking  on  a  cystic  type  of  development,  which 
usually  is  quite  benign,  it  may  undergo  an  adenomatous  transforma- 
tion, in-growths  occurring  from  the  ducts  or  cyst  walls  into  the  sur- 
rounding stroma;  and  in  about  10  or  15  per  cent,  of  cases  the  disease 
terminates  as  a  carcinoma  (Speese,  1910).  It  is  on  this  account  that 
its  early  recognition  and  proper  treatment  are  so  important. 

Diagnosis. — In  its  onset  this  affection  of  the  breasts  resembles 
chronic  mastitis,  and  by  many  it  is  still  considered  infectious  in  origin. 
There  seems  to  be  no  doubt  that  previous  attacks  of  mastitis  pre- 
dispose the  patient  to  the  development  of  this  disease.  And  in  some 
cases  it  is  nearly  impossible  to  say  off-hand  that  this  is  a  case  of 
diffuse  chronic  mastitis  and  not  one  of  "abnormal  involution,"  or 
vice  versa.  I  have  preferred  to  discuss  the  disease  entirely  in  one  place, 
and  for  this  reason  have  described  only  a  localized  and  not  a  diffuse 
form  of  chronic  mastitis  (p.  751).  From  cystadenoma  of  the  breast 
(p.  761)  its  differentiation  also  is  difficult  especially  in  the  later  stages; 
but  as  a  rule  even  in  such  cases  the  diffuse  nature  of  the  process  is 
evident.  While  the  cystadenoma  is  at  first  a  localized  growth,  it 
increases  in  size  much  more  rapidly  than  does  the  breast  which  is 
the  seat  of  diffuse  cystadenomatosis;  and  only  after  the  latter  con- 
dition has  existed  for  many  years  will  cysts  be  present  commensurate 
in  size  with  those  of  a  cystadenoma  of  some  months'  duration.  As 
in  this  stage  the  treatment  for  both  affections  is  the  same  (amputation 
of  the  breast),  the  distinction  is  not  of  great  importance. 

Treatment. — 1.  If  the  woman  is  young  (under  thirty-eight  years),  the 
cystadenomatoid  change  recently  discovered  and  presumably  of  slow 
growth,  she  should  be  kept  under  strict  surgical  observation,  a  careful 
manipular  examination  of  the  breasts  being  made  at  monthly  inter- 
vals. Meantime  such  general  hygienic  measures,  changes  in  clothing 
and  habits  of  life,  and  attention  to  menstrual  derangements  should 
be  enforced  as  seem  indicated.  Local  treatment  has  little  value,  but 
such  as  was  recommended  for  chronic  mastitis  (p.  752)  is  at  least  harm- 
less. If  the  condition  remains  stationary,  or,  still  better,  if  it  seems 
to  subside,  well  and  good;  no  operation  is  required.  If  it  continues 
to  progress,  the  breast  (often  both  of  them)  must  be  operated  on. 
The  operation  may  be  begun  by  an  exploratory  incision,  as  in  the 
method  of  "plastic  resection"  of  the  breast  (p.  760);  when  the  gland 
tissue  is  exposed  and  incised,  the  subsequent  course  of  the  operation 
will  depend  on  what  is  found.  If  only  one  or  two  fairly  large  cysts 
are  found,  and  no  suspicion  of  malignancy  exists,  it  is  sufficient  to 
excise  the  cysts  and  leave  the  greater  portion  of  the  gland  intact. 
If  a  number  of  cysts  are  present  the  entire  breast  should  be  ampu- 
tated, as  described  below.  If  any  suspicion  of  malignancy  exists, 
the  axilla  should  be  exposed,  cleared,  and  its  contents  should  be 
removed  in  one  mass  with  pectoral  muscles,  mammary,  gland,  and 
overlying  skin. 

2.  If  the  woman  is  past  the  age  of  greatest  functional  activity  of 


FIBRO-ADENOMATOUS  TUMORS'  759 

the  mammary  glands  (and  this  age  varies  in  individuals  as  in  different 
races),  it  is  better  to  remove  the  breasts  at  once,  since  the  probability 
of  actual  or  subsequent  malignant  change  is  much  greater  at  this 
period  of  life. 

Whenever  the  breast  is  removed  it  should  be  most  scrupulously 
examined  macroscopically ;  any  and  every  area  suggesting  malignancy 
should  then  be  studied  microscopically  by  a  competent  pathologist. 
Such  areas  are  intracystic  papillomatous  growths,  or  areas  of  greater 
density  or  of  ulceration  in  the  cyst  walls.  Only  one  very  minute 
area  such  as  this  may  be  present  in  the  entire  gland,  and  it  is  very 
easily  overlooked.  The  question  of  malignancy  should  be  decided, 
as  it  is  vital  for  prognosis  and  the  patient's  peace  of  mind. 

I  place  no  reliance  at  all  on  diagnoses  made  during  the  progress 
of  the  operation  from  microscopical  study  of  frozen  sections;  yet 
I  know  that  some  very  experienced  surgeons  still  deem  this  method 
of  value.  The  macroscopical  appearance  of  the  breast  should  be  a 
better  guide  to  the  surgeon,  and  my  own  judgment  agrees  with  that  of 
Bloodgood  and  others,  that  no  surgeon  should  be  satisfied  to  operate 
on  these  borderline  cases  unless  he  has  the  skill  and  knowledge  to 
differentiate  clinically  at  the  time  of  operation  between  growths 
certainly  benign  and  those  possibly  malignant. 

Amputation  of  the  Breast.— An  incision  is  made  in  the  submammary 
crease,  from  the  anterior  axillary  fold  inward  to  the  parasternal 
line.  The  lower  edge  of  the  pectoralis  major  is  exposed,  and  the 
mammary  gland  thrown  upward  on  the  patient's  chest.  The  gland 
can  then  be  explored  from  the  posterior  surface.  If  amputation, 
instead  of  plastic  resection  or  radical  ablation,  is  determined  upon, 
a  curved  incision  is  then  made  above  the  breast,  joining  the  ends  of 
that  already  made.  The  flaps  are  dissected  up  sufficiently  to  ensure 
complete  removal  of  all  glandular  tissue.  The  wide  area  over  which 
this  may  be  spread  should  be  remembered  (p.  770).  The  surface  of 
the  pectoralis  major  is  then  exposed  above  and  the  fascia  is  dissected 
from  it  downward.  Bleeding  points,  chiefly  branches  of  the  inter- 
costals,  are  clamped  as  severed.  The  superficial  fibers  of  the  muscle 
are  removed,  and  the  mammary  gland  is  excised  in  one  piece  with  the 
nipple  and  overlying  skin,  the  surrounding  fat,  and  the  pectoral  fascia. 
Hemorrhage  being  controlled  by  ligature,  the  wound  is  closed  with 
interrupted  sutures,  and  provision  is  made  for  drainage  for  a  few  days. 

Benign  Tumors. — Benign  tumors  of  the  breast  are  rare.  They  occur 
mostly  in  young  women,  from  fifteen  to  thirty  years  of  age,  and  in 
almost  all  cases  are  fibro-epithelial  in  type  (Ribbert,  1901).  They  are 
conveniently  divided,  as  is  done  by  Warren,  into  two  subdivisions:  (1) 
Those  in  which  the  fibrous  element  predominates — fibro-adenoma;  and 
(2)  those  in  which  the  epithelial  element  is  conspicuous — cyst-adenoma. 

1.  Fibro- adenomatous  Tumors. — These  are  particularly  character- 
ized by  neoplastic  growth  of  the  stroma  which  surrounds  the  gland 
ducts;  hence  they  are  all  described  as  periductal  tumors.  If  the  tumor 
is  mostly  pure  fibrous  tissue,  like  that  found  in  the  virgin  breast, 


760  SURGERY  OF  THE  BREAST 

it  is  called  a  periductal  fibroma;  and  the  fibromatous  change  may  be 
either  intracanalicular  in  type,  or  pericanalicular:  in  the  former 
case  the  fibromatous  tissue  compresses  and  distorts  the  duets,  so  that 
these  appear  as  curved  slits  or  chinks  in  the  microscopical  field; 
while  in  the  pericanalicular  form  the  normal  appearance  of  the 
ducts  is  largely  preserved.  In  most  cases,  instead  of  a  pure  fibro- 
matous tumor,  there  is  myxomatous  degeneration  of  the  fibroma,  and 
the  growth  is  known  as  a  periductal  myxoma;  this  is  the  form  most 
frequently  encountered,  though  probably  at  an  earlier  stage  the 
tumor  was  more  purely  fibromatous.  In  rare  cases,  the  stroma  of  the 
tumor  instead  of  being  fibromatous  or  myxomatous  is  sarcomatous, 
and  the  growth  is  called  periductal  sarcoma. 

Symptoms  and  Clinical  Course. — Usually  occurring  in  young 
unmarried  women,  these  growths  well  deserve  the  name  "chronic 
mammary  tumor"  bestowed  upon  them  by  Sir  Astley  Cooper.  They 
present  few  symptoms  other  than  the  presence  of  a  "lump  in  the 
breast,"  which  usually  is  discovered  accidentally,  and  may  be  attrib- 
uted to  injury.  When  of  long  duration  a  visible  swelling  may  exist. 
This  swelling  or  lump  is  in  the  central  portion  of  the  gland,  but  not 
close  to  the  nipple.  It  feels  hard,  is  well  defined  from  the  rest  of  the 
gland,  is  not  tender,  and  seldom  is  movable  except  in  one  mass  with 
the  breast.  Palpation  of  the  breast  with  the  flat  hand,  pressing  it 
against  the  chest,  demonstrates  the  presence  of  an  actual  tumor;  the 
lump  does  not  vanish  as  does  that  due  to  chronic  mastitis,  when  this 
manoeuvre  is  adopted.  The  overlying  skin  is  not  affected,  nor  are  the 
axillary  nodes  enlarged.  The  tumor  grows  very  slowly,  and  may 
remain  for  years  in  much  the  same  condition.  Occasionally,  however, 
rapid  growth  occurs;  this,  of  course,  is  a  bad  omen.  But  in  most 
cases  the  prognosis  is  absolutely  good. 

Treatment.- — The  tumor  should  be  removed.  It  is  encapsulated, 
and  by  exposing  the  posterior  surface  of  the  mammary  gland,  as 
described  below,  the  growth  can  be  enucleated,  the  breast  replaced, 
and  no  visible  scar  will  remain.  This  method  of  plastic  resection  of 
the  breast,  introduced  in  1882  by  T.  Gaillard  Thomas,  was  revivified  by 
J.  Collins  Warren.  It  is  thus  performed:  An  incision  is  made  from  the 
anterior  axillary  fold  inward  in  the  submammary  crease,  as  far  as  the 
inner  lower  quadrant  of  the  breast.  This  incision  is  deepened  to  expose 
the  pectoralis  major,  and  the  mammary  gland  is  dissected  from  its 
surface  and  is  thrown  upward  on  the  patient's  chest.  As  the  main 
blood-supply  of  the  gland  enters  it  from  its  superficial  surface,  near  its 
upper  border,  no  fear  of  sloughing  need  be  felt.  The  posterior  surface 
of  the  gland  being  thus  brought  to  view,  the  region  of  the  tumor  is 
exposed  by  an  incision  radiating  from  the  center ;  the  tumor  is  enucleated 
and  the  cavity  is  obliterated  by  catgut  sutures,  thus  restoring  the 
contour  of  the  breast.  This  is  then  replaced  on  the  pectoral  muscle, 
and  the  deep  layer  of  the  superficial  fascia  carefully  sutured,  so  as  to 
retain  the  breast  in  place;  and  the  skin  is  closed  with  provision  for 
drainage. 


CYSTADENOMATOUS  TUMORS  761 

2.  Cystadenomatous  Tumors. — These  seem  to  represent  a  later 
development  of  the  fibro-adenomatous  tumors  just  described;  and 
as  nearly  all  growths  in  the  breast  at  the  present  day  are  removed 
soon  after  their  presence  is  discovered,  it  results  that' cystadenomatous 
tumors  are  much  more  rare  now  than  fifty  or  one  hundred  years  ago. 
At  that  time  the  curious  combination  of  fibrous  and  epithelial  pro- 
liferation, resulting  in  solid  (perhaps  sarcomatous)  tumors  filled 
with  cysts,  was  productive  of  great  confusion  as  regards  nomenclature. 
This  class  of  tumor  was  described  by  Astley  Cooper  as  hydatid  disease 
of  the  breast;  Brodie  called  it  sero-cystic  sarcoma;  Paget  named  them 
proliferous  mammary  cysts;  and  Johannes  Miiller  used  the  term 
cysto-sarcoma  phyllodes,  both  the  latter  observers  laying  special  stress 
on  the  occurrence  of  intracystic  papillary  out-growths  To  the  present 
day  the  French  call  it  adeno-sarcoma. 

The  growth  consists,  in  fact,  of  a  cystic  tumor,  with  a  more  or 
less  abundant  fibrous  stroma — a  fibrocysiadenoma.  The  cysts  are 
of  various  sizes,  usually  some  of  them  quite  large.  Their  lining 
membrane  may  be  quite  smooth,  as  if  from  pressure  atrophy.  Almost 
invariably  from  one  or  more  areas  of  the  cyst  wall,  papillomatous 
growths  project — papillary  cystadenoma.  These  intracystic  growths 
have  a  solid  core  of  fibrous  tissue,  and  they  may  completely  fill  the 
cyst  and  even  cause  its  distention.  It  seems  as  if  the  proliferation  of 
the  stroma  had  converted  the  semi-circular  chinks  or  slits  of  the 
intracanalicular  fibroma  into  actual  cysts  formed  by  the  pressure  of 
papillary  out-growths  into  the  duct  lumen.  This  impression  is  con- 
firmed by  the  fact  that  the  papillomas  are  covered  with  cells  which 
present  the  characteristics  of  ductal  rather  than  of  acinal  epithelium. 
The  small  amount  of  fluid  which  the  cysts  contain  may  be  colorless, 
slightly  tinged  with  yellow  or  green,  but  usually  is  brownish  or  hem- 
orrhagic in  nature. 

Symptoms  and  Clinical  Course. — These  tumors  occur  in  older  women 
than  do  the  fibro-adenomatous  growths.  The  average  age  in  Warren's 
patients  was  fifty-two  years.  Indeed,  in  most  cases  where  cysts 
are  found  in  the  mammary  gland  it  is  an  indication  that  this  organ 
has  reached  its  full  maturity  before  the  tumor  began  to  grow.  Cyst- 
adenoma  grows  more  rapidly  than  the  solid  benign  tumors,  and  if 
not  removed,  may  reach  a  large  size.  The  growth  is  situated  in  the 
central  part  of  the  breast,  beneath  the  nipple  or  areola,  and  at  first 
presents  much  the  same  features  as  the  fibro-adenoma.  In  the  course 
of  a  few  years,  however,  the  presence  of  cysts  usually  may  be  sus- 
pected from  the  lobulated  nature  of  the  tumor,  and  sometimes  from 
distinct  fluctuation.  But  the  latter  rarely  occurs,  since  the  cysts 
are  apt  to  be  filled  with  the  papillary  out-growths,  which  give  them 
a  solid  feel.  The  overlying  skin  is  not  altered,  the  axillary  nodes 
are  not  enlarged,  and  seldom  is  the  general  health  affected.  Very 
often  there  is  a  bloody  discharge  from  the  nipple.  In  very  advanced 
cases  the  skin  overlying  one  of  the  cysts  may  become  thinned,  and  a 
semitranslucent  appearance  may  be  present.     The  breast  may  be 


762  SURGERY  OF  THE  BREAST 

covered  with  a  network  of  distended  veins.  Finally,  as  in  the  most 
advanced  stages  of  cystadenomatosis  (p.  756)  perforation  of  the  skin 
may  occur,  with  the  protrusion  of  the  intracystic  papillomas  as  a 
fungus  growth.  At  any  stage  of  the  disease  malignant  changes  may 
occur.  These  may  develop  in  the  epithelial  elements  (carcinoma), 
or  rarely  in  the  stroma  (sarcoma.) 

Diagnosis.- — The  diagnosis  must  be  made  from  fibro-adenoma, 
and  from  cystadenomatosis.  From  the  former,  cystadenoma  usually 
may  be  distinguished  by  the  greater  age  of  the  patient,  by  the  less 
dense  feel  and  less  definite  outline  which  the  growth  presents;  as 
well  as  by  its  more  rapid  enlargement  and  its  eventually  cystic  char- 
acter. From  cystadenomatosis  of  the  breast  the  distinction  is  difficult 
only  in  the  later  stages,  when  the  primarily  local  tumor  (cystadenoma) 
has  grown  so  large  as  to  occupy  nearly  the  entire  area  of  the  mammary 
gland. 

Treatment. — Ablation  of  the  breast,  pectoral  muscles,  and  axillary 
lymphatics,  as  for  carcinoma,  is  the  safest  treatment  in  patients 
over  thirty-eight  or  forty  years  of  age.  In  younger  patients,  in 
whom  malignant  changes  are  less  likely,  amputation  of  the  breast 
is  sufficient. 

Other  benign  tumors  occur  in  the  breast,  but  are  extremely  rare, 
and  present  only  pathological  interest.  A  pure  adenoma  was  described 
by  S.  W.  Gross  (1880)  and  by  Rodman:  it  is  a  soft,  succulent,  nodular, 
rather  rapidly  growing  tumor,  not  very  well  encapsulated,  and  affecting 
young  women.  Lipoma  may  occur  in  the  interlobular  tissues  of  the 
mammary  gland,  in  the  subcutaneous  fat  overlying  it,  or  in  the  sub- 
mammary tissues.  Cases  of  angeioma  and  endothelioma  have  also 
been  recorded.  Enchondroma  is  another  rare  growrth,  developing  here, 
as  in  the  salivary  glands,  in  the  form  of  a  "mixed  tumor,"  with  areas 
of  cartilage  and  calcareous  matter.  The  diagnosis  of  these  rare  growths 
sometimes  is  not  made  until  after  removal,  which  is  the  proper  treatment. 

Malignant  Tumors  of  the  Breast. — The  general  character  of  malignant 
as  distinguished  from  benign  tumors  was  indicated  in  Chapter  IV, 
and  it  is  not  necessary  to  repeat  this  discussion  here.  It  is  enough 
to  say  that  over  70  per  cent,  of  tumors  of  the  breast  are  malignant, 
and  that  in  women  approaching  or  past  the  menopause  every  tumor 
should  be  regarded  as  malignant,  and  should  be  treated  accordingly. 

Sarcoma.— Sarcoma  is  very  rare.  It  occurs  in  less  than  3  per  cent, 
of  cases  of  mammary  neoplasm.  Reference  was  made  at  p.  760 
to  a  form  of  periductal  sarcoma,  which  is  classed  among  the  benign 
tumors.  This  forms  about  80  per  cent,  of  the  cases  of  sarcoma  of  the 
breast  on  record,  a  fact  which  emphasizes  the  exceeding  rarity  of 
true  mammary  sarcoma.  This  truly  malignant  form  of  sarcoma  which 
forms  only  20  per  cent,  of  the  recorded  cases  of  mammary  sarcoma, 
is  of  the  spindle-  or  round-celled  type,  and  epithelial  proliferation  is 
scanty  or  absent.  The  tumor  affects  women  at  any  age,  probably 
most  often  those  between  forty  and  fifty  years.  At  first  it  is  a  well 
defined,  small,   indolent  mass,   which  may  cause  no  symptoms  for 


PLATE     XI 


Adenocarcinoma  of  Left  Breast. 


Patient  aged  sixty-nine  years;  duration  unknown  (patient  was  insane).  Section  shows 
a  soft,  well-defined  tumor,  with  cystic  areas.  On  account  of  patient's  mental  condition 
and  physical  incapacity,  mere  amputation  of  the  breast  was  done.  Three  years 
later  she  was  reported  as  confined  to  the  house  with  "dropsy  and  an  abdominal  tumor" 
(evidently  metastatic  carcinoma).     Episcopal  Hospital. 


PLATE    XII 


m 


V* 


Scirrhous  Carcinoma  of  Breast. 

Specimen  (half  natural  size)  from  excision  of  right  breast  for  carcinoma.  Aged  forty- 
five  years ;  duration  two  and  a  half  years,  ulcerated  six  months.  Tumor  developed  a  few 
months  after  direct  trauma.  Xote  the  "rose  ulcer"  in  the  upper  outer  quadrant,  measur- 
ing 8x5  cm.  and  covered  with  adherent  gray-green  slough;  beneath  this  was  a  hard  tumor 
the  -ize  of  a  goose  egg  (Plate  XIII),  not  attached  to  chest  wall.  Visible  mass  in  axilla. 
Tumor,  pectoral  muscles  and  axillary  structures  removed  in  one  mass.  (August,  1912). 
Patient  in  good  health  and  free  from  recurrence  or  metastasis  more  than  seven  years 
after  operation.     Episcopal  Hospital. 


CARCINOMA 


763 


years.  Eventually,  however,  rapid  growth  sets  in,  the  tumor  breaks 
through  its  imperfect  capsule,  infiltrates  the  mammary  gland,  causes 
distention,  redness,  and  sloughing  of  the  overlying  skin,  and  in  a  few 
months  or  even  weeks  there  is  a  protruding,  fungus,  bleeding  mass 
(fungus  nematodes).  The  diagnosis  is  difficult  in  the  early  stages; 
when  seen  at  this  time  the  growth  may  be  mistaken  for  a  benign 
tumor.  Treatment  consists  in  early  amputation  of  the  breast;  the 
axillary  lymphatics  very  rarely  are  involved,  but  in  patients  past 
thirty-eight  or  forty  years  it  is  a  wise  precaution  to  substitute  ablation 
for  amputation,  as  in  cases  of  carcinoma. 

Carcinoma. — Carcinoma  is  the  most  frequent  affection  of  the 
breast.  Only  about  1  per  cent,  of  cases  occur  in  the  male  breast 
(Fig.  819).  "  Most  tumors  of 
the  breast  in  women  over  forty 
years  of  age  are  carcinomatous, 
but  the  disease  is  not  at  all 
infrequent  at  an  earlier  age. 
The  older  the  patient,  the 
more  apt  is  a  tumor  to  be 
carcinomatous.  The  left  and 
right  breasts  are  affected  with 
about  equal  frequency.  Very 
rarely  are  both  breasts  simulta- 
neously attacked  (in  about  1  per 
cent,  of  cases),  but  the  disease 
may  spread  from  one  gland  to 
the  other  through  the  lymph- 
atics (Fig.  820).  Heredity  has 
little  influence  in  the  clinical 
etiology  of  the  affection,  nor 
has  race.  It  is  more  frequent 
in  married  than  unmarried 
women,    particularly   in  those 

who  have  borne  and  suckled  children.  The  influence  of  direct  trauma 
seldom  is  noted  (Plate  XII). 

Pathology. — A  tumor  of  the  mammary  gland  may  begin  as  a  car- 
cinoma, or  carcinoma  may  develop  in  a  previously  existing  benign 
tumor.  The  latter  is  much  the  rarer;  it  oftenest  succeeds  the  change 
described  as  abnormal  involution  of  the  breast  (p.  756)  and  assumes 
the  type  of  adeno-carcinoma,  or  "duct  cancer"  (p.  126).  In  this  form 
the  tumor  lies  near  or  beneath  the  nipple,  which  is  not  retracted 
(Plate  XI) ;  the  growth  is  soft,  shows  little  tendency  to  infiltrate,  but 
early  breaks  through  the  skin,  and  appears  as  an  ulcer  without  the 
hard  and  thickened  margins  so  characteristic  of  the  commoner  types 
of  carcinoma,  and  having  its  surface  not  depressed  but  rather  ele- 
vated above  the  surrounding  skin.  Rarely  does  this  growth  long  pre- 
serve the  relatively  benign  character  of  an  adeno-carcinoma;  it  soon 
proliferates  in  an  atypical   manner  like  the  solid-celled  carcinoma. 


Fig.  819. — Scirrhous  carcinoma  of  male 
breast,  age  fifty-nine  years;  duration  three 
years;  rapid  growth  for  one  year.  Axillary 
nodes  palpable.  (Dr.  J.  P.  Hutchinson's 
case.)     Pennsylvania  Hospital. 


764 


SURGERY  OF  THE  BREAST 


The  latter,  which  is  the  usual  form  of  carcinoma  seen  in  the  breast, 
arises  in  an  atypical  proliferation  of  the  epithelial  cells  lining  the 
acini  of  the  gland,  and  thus  is  distinguished  from  the  rarer  and  less 
malignant  duct-cancer  by  the  term  acinous  carcinoma. 

The  microscopical  features  of  adeno-carcinoma  and  solid-celled 
carcinoma  were  considered  at  p.  120.  Clinically,  the  usual  type  of 
mammary  carcinoma,  that  classed  as  solid-celled,  is  encountered  in 
three  varieties  dependent  upon  the  relative  amount  of  stroma  present: 
Scirrhous  Carcinoma,  in  which  stroma  is  very  abundant  and  cellular 
elements  scanty;  Carcinoma  Simplex,  in  which  stroma  and  epithelial 
elements  exist  in  equal  amount;  and  Medullary  Carcinoma,  in  which 
the  epithelial  elements  are  very  abundant  and  the  stroma  is  scanty. 
The  clinical  features  of  these  three  forms  mav  be  now  briefly  considered. 


Fig.  820. — Carcinoma  simplex  of  both  breasts,  age  sixty-six  years.  Growth  in  left 
breast  for  five  years,  ulcerated  five  months;  large  sloughing  ulcer;  axillary  nodes  palpable. 
Growth  in  right  breast  for  two  years:  skin  red  and  adherent;  nipple  retracted;  axillary 
nodes  palpable.  Palliative  amputation  of  both  breasts  in  October,  1909,  with  prolonged 
after-treatment  by  x-rays.  (Dr.  Thos.  S.  Stewart.)  In  September,  1911,  a  metastatic 
growth  appeared  in  right  thigh.  In  August,  1913,  mediastinal  and  pulmonary  metastases, 
but  no  local  recurrence.  In  January,  1914,  feeble,  but  little  discomfort.  Death  in 
March,  1914.     Episcopal  Hospital. 


Scirrhous  Carcinoma,  or  simply  Scirrhus,  is  the  most  frequent 
form  of  mammary  cancer.  Owing  to  the  abundance  of  the  stroma 
the  tumor  is  quite  hard;  it  seems  as  if  the  surrounding  tissues  were 
endeavoring  to  stifle  the  growth  of  the  epithelial  elements.  On 
section  the  tumor  is  found  to  be  absolutely  continuous  with  the 
surrounding  tissues;  there  is  not  the  slightest  indication  of  a  capsule; 
it  is  impossible  to  remove  the  tumor  from  the  gland.  It  is  hard, 
and  creaks  when  cut  by  the  knife.  Usually  both  the  cut  surfaces  are 
found  to  be  concave;  it  is  as  if  the  tumor  were  too  small  for  the  tissues 
in  which  it  grew,  and  tended  to  contract  further  at  the  first  opportunity. 
The  surface  of  the  section  often  has  been  likened  to  that  of  an  unripe  pear 
(Plate  XIII) :  it  is  pale  and  shiny,  grayish  white  at  first,  but  becomes 


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pinkish  on  exposure  to  the  air.  Usually  there  are  yellow  dots  scat- 
tered over  the  surface  of  the  section;  these  are  either  spots  of  fatty 
degeneration,  or  areas  of  fatty  tissues  not  yet  strangulated  by  the 
fibrous  stroma.  On  scraping  the  section  with  the  knife,  "cancer- 
juice"  is  produced;  but  this  is  no  longer  regarded  as  particularly 
characteristic  of  carcinoma. 

Symptoms  and  Clinical  Course. — The  patient  finds  a  lump  in  her 
breast,  but  rarely  are  there  any  subjective  symptoms.  There  may 
be  occasional  lancinating  pains,  but  the  tumor  is  not  tender,  a  fact 
which  distinguishes  it  from  all  inflammatory  swellings.  This  lump 
in  most  cases  lies  in  the  per- 
iphery of  the  mammary  gla?id, 
not  near  the  nipple;  and  is 
found  oftenest  in  the  upper 
outer  quadrant.  It  is  hard, 
but  not  definitely  outlined, 
when  felt  between  the  thumb 
and  fingers;  and  it  is  still  pal- 
pable as  a  dense  nodule  when 
the  breast  is  pressed  by  the 
palm  of  the  hand  flat  against 
the  patient's  chest.  This  dis- 
tinguishes it  from  non-neoplas- 
tic  thickenings  of  the  mammary 
gland.  Owing  to  the  abundance 
of  the  fibrous  stroma  and  its 
tendency  to  contract,  the  size 
of  the  breast  usually  is  dimin- 
ished in  cases  of  scirrhus;  when 

this  contraction  is  extreme,  the  condition  is  named  atrophic  or 
withering  scirrhus  (Fig.  821).  An  early  and  valuable  sign  due  to 
this  contracting  tendency  has  been  pointed  out  by  Halsted:  this 
is  limitation  of  the  excursions  on  the  chest  wall  of  the  affected  mamma 
as  compared  with  the  normal  gland.  If  the  breast  is  pulled  from  side 
to  side,  and  up  and  down,  even  in  the  case  of  a  small,  deeply  seated, 
and  almost  impalpable  nodule,  it  will  be  found  that  the  excursions 
of  the  affected  breast  are  diminished,  especially  in  a  direction  away 
from  the  axilla.  The  cancer  cells  extend  along  planes  of  fascia  in  all 
directions,  and  the  abundant  fibrous  stroma  follows  them  up,  as  if 
in  the  endeavor  to  strangle  them  by  its  contraction.  This  extension 
and  subsequent  contraction  limits  the  excursions  of  the  breast,  pulls 
the  nipple  down  into  the  gland  {retraction  of  the  nipple),  and,  through 
the  ligamenta  suspensoria  of  Sir  Astley  Cooper,  causes  the  typical 
dimpling  of  the  overlying  skin  resembling  an  orange  or  pig  skin 
(Fig.  823).  Thus  quite  early  the  overlying  skin  becomes  fixed  to 
the  growth,  and  the  growth  becomes  fixed  to  the  pectoral  fascia.  The 
axillary  lymphatics  are  not  palpably  enlarged  early  in  the  disease,  but 
they  are  microscopically  invaded  long  before  theyjbecorne  [palpable. 


Fig.  821. — Atrophic  or  withering  scirrhus 
of  breast.  Age  seventy-five  years;  growth 
noticed  only  a  little  over  a  year  ago;  ulcer- 
ated for  six  months.  Has  had  no  treatment, 
and  the  growth  is  now  adherent  to  the  ribs 
and  inoperable.     Episcopal  Hospital. 


71  ill 


SURGERY  OF  THE  BREAST 


The  diagnosis  should  be  made  before  this  complication  <>r  ulceration  of 
the  skin  develops.  Ulceration  is  a  late  stage  of  the  disease,  usually  not 
appearing  for  one  or  two  years  after  the  development  of  the  tumor. 
In  some  cases  (atrophic  scirrhus)  ulceration  may  never  occur.  When 
it  develops  it  is  due  to  gradual  invasion  of  the  skin  by  the  cancerous 
growth;  a  small  ulcer  first  appears,  and  this  gradually  increases  in 
size.  The  scirrhous  ulcer  is  quite  typical:  it  is  more  or  less  circular 
in  outline,  fixed  to  the  chest  wall,  red,  dry,  and  quite  dense;  colloqui- 
ally it  is  known  as  the  "rose  ulcer"  (Fig.  822).  Occasionally  as  a 
primary  growth,  but  more  often  as  a  recurrence  after  operation, 
carcinoma  grows  either  in  many  apparently  isolated  spots  over  the 
chest  wall,  or  widely  diffused  in  the  skin;  this  is  known  as  "squirrhe 
en  cuirasse,"  as  if  the  patient  was  covered  with  a  "coat  of  mail" 
composed  of  carcinomatous  nodules  (Fig.  824). 


Fig.  822. — Scirrhous  carcinoma  of  breast  showing  typical  "rose  ulcer."  Age  sixty- 
eight  years;  duration  three  years;  ulcerated  six  months.  Has  had  no  treatment,  and 
growth  is  now  adherent  to  ribs  and  inoperable.  Two  years  and  six  months  later,  there 
was  a  large  stinking  ulcer,  patient  was  extremely  emaciated,  hardly  able  to  stand,  and 
suffered  dreadful  pain.    Episcopal  Hospital. 


Prognosis  and  Treatment. — Owing  to  the  slow  growth  and  few 
subjective  symptoms  produced  by  the  tumor,  the  patient  often 
does  not  seek  surgical  advice  until  fixation  and  perhaps  ulceration 
have  occurred.  The  average  duration  of  life  in  untreated  cases  of 
scirrhus  is  from  two  and  a  half  to  three  years.  The  more  atrophic 
the  type,  the  longer  will  death  be  delayed;  sometimes  the  patient 
drags  out  a  painful  existence  for  twenty  years.  If  radical  operation 
is  done  before  fixation  of  the  tumor,  so  that  it  is  possible  to  remove 
all  of  the  disease,  freedom  from  recurrence  for  three  years  or  more 
(which  is  classed  as  "ultimate  cure")  will  result  in  from  50  to  70 
per  cent,  of  cases  so  treated.  The  reasons  why  operation  should  be 
urged,  even  with  no  better  prospects,  are  stated  at  p.  774;  and  the 
question  of  operability  is  discussed  in  the  same  place.  In  inoperable 
cases  palliative  treatment,  as  outlined  in  Chapter  IV,  is  indicated. 


CARCINOMA  SIMPLEX  OR  ACUTE  SCIRRHUS 


767 


Carcinoma  Simplex  or  Acute  Scirrhus  is  an  intermediate  form  between 
the  scirrhous  and  medullary  types.     The  tumor  causes  increase  in 


Fig.  S23. — Carcinoma  simplex  of  left  breast.  Age  forty-four  years;  duration  seven 
months,  from  recurring  trauma  from  work  in  mill.  Note  pig-skin  dimpling,  retraction 
of  nipple,  breast  standing  out  from  thorax;  emaciated  face,  and  anxious  expression. 
(See  Fig.  824.)     Dr.  C.  H.  Frazier's  patient.     Episcopal  Hospital. 


Fig.  824. — Recurrent  carcinoma  of  breast  one  year  after  excision.  Note  cancer  en 
cuirasse,  fatter  face  and  less  anxious  expression  since  being  under  hospital  care;  edema 
of  left  arm ;  involvement  of  right  axilla.  Two  and  a  half  years  after  operation,  condition 
no  worse,  growth  seemingly  held  in  check  by  constant  z-ray  treatments.  (Dr.  Thos.  S. 
Stewart.)     No  pain,  less  edema  of  arm.    Episcopal  Hospital. 


the  size  of  the  breast,  and  grows  rapidly;  the  axillary  lymphatics 
are  palpably  involved  quite  early  in  the  disease,  and  all  local  symptoms 


70S  SURGERY  OF  THE  BREAST 

(limitation  of  excursion  of  the  breast,  retraction  of  the  nipple,  orange 
skin  dimpling)  occur  sooner  than  in  the  scirrhous  form  (Fig.  823). 
Ulceration  also  develops  earlier  and  the  ulcer  is  deeper  but  is  not 
fixed  to  the  chest  wall;  its  surface  is  covered  with  sloughs,  there  is 
more  discharge,  and  hemorrhages  may  occur  (Fig.  820). 

Prognosis  and  Treatment. — On  account  of  the  more  rapid  growth 
of  the  tumor,  the  patient  usually  seeks  advice  sooner  than  in  the 
scirrhous  form,  and  therefore  radical  treatment  more  often  can  be 
undertaken  with  a  hope  of  cure. 

Medullary  Carcinoma  is  much  rarer  than  either  scirrhus  or  carcinoma 
simplex.  The  tumor  occurs  in  younger  women,  and  is  of  extremely 
rapid  growth,  often  simulating  a  phlegmonous  process.  The  over- 
lying skin  is  red  and  tense;  the  breast  is  covered  with  dilated  veins, 
and  feels  hot  on  palpation;  soft  areas  resembling  suppurating  cysts 
or  abscesses  may  be  felt;  and  in  the  course  of  a  few  weeks  the  whole 
surface  of  the  tumor  breaks  down,  and  a  foul,  sloughing  mass  pro- 
trudes. Hemorrhages  are  frequent,  and  large  clots  may  cover  the 
surfaces  of  the  mass  (Fungus  Hematodes).  On  section  the  tumor 
often  resembles  softened  brain  matter,  whence  it  sometimes  is  called 
encephaloid;  it  is  friable  and  pulpy.  An  extreme  type  of  medullary 
carcinoma,  with  most  alarmingly  rapid  growth,  frequently  developing 
during  pregnancy,  is  described  as  carcinomatous  mastitis.  This  often 
involves  both  breasts. 

Prognosis  and  Treatment. — Death  usually  occurs  within  a  few 
months,  even  early  radical  operation  proving  ineffectual  in  preventing 
recurrence.  Those  tumors  developing  during  pregnancy  are  the  most 
malignant  of  all. 

Paget's  Disease  of  the  Nipple. — This  was  described  by  Sir  James 
Paget,  in  1874,  as  a  form  of  dermatitis  or  eczema  predisposing  to 
carcinoma  of  the  breast.  It  is  a  rare  disease,  and  while  almost  all 
cases  occur  in  the  nipple  of  the  female  breast,  a  few  have  been  recorded 
as  occurring  in  other  parts  of  the  body.  The  exact  nature  of  the 
affection  is  still  disputed  by  pathologists.  Most  authorities  consider 
it  carcinomatous  from  the  beginning,  but  its  point  of  origin  is  un- 
determined. Some  hold  that  it  arises  in  the  galactophorous  ducts 
and  invades  the  skin  secondarily;  others  believe  that  it  originates  in 
the  epidermis  and  invades  the  ducts  secondarily.  Microscopically 
the  characteristic  feature  is  the  presence  of  large  transparent  multi- 
nucleated cells  ("Paget  cells")  in  the  deeper  layers  of  the  epidermis. 
Clinically  the  disease  affects  women  of  the  cancer  age;  it  begins  as  a 
scaly  affection  of  the  nipple,  typically  eczematous  in  nature  but  totally 
uninfluenced  by  local  remedies  usually  effectual  in  relieving  eczema 
in  other  parts  of  the  body.  As  the  disease  progresses,  the  areola  is 
involved,  and  the  erosion  or  excoriation  continues  to  spread  super- 
ficially for  months  before  the  glandular  tissue  is  noticeably  affected. 
The  area  usually  is  moist,  but  some  psoriasis-like  cases  have  been 
reported.  The  subjective  symptoms  are  itching,  tingling,  and  burning; 
but  the  general  health  is  not  impaired. 


EXTENSION  OF  MAMMARY  CARCINOMA 


769 


Treatment. — Treatment  consists  in  amputation  of  the  breast  as 
soon  as  the  disease  is  recognized;  if  the  disease  is  extensive  or  of  long 
duration,  it  is  safer  to  do  a  radical  operation  as  for  carcinoma. 

Cancer  Cyst. — This  is  the  rarest  form  in  which  malignant  disease 
of  the  breast  occurs.  It  has  been  studied  by  Bloodgood  (1907). 
Usually  occurring  as  a  single  cyst,  it  grows  slowly,  and  presents 
few  clinical  signs  of  malignancy.  Exploratory  operation  being  under- 
taken, the  cyst  is  found  to  contain  bloody  fluid,  and  there  is  no  intra- 
cystic  papillomatous  out-growth  to  account  for  this  fact;  but  usually 
an  indurated  or  ulcerated  area  is  found  in  the  cyst  wall.  Any  cyst 
which  is  opened  at  operation,  and  is  found  to  contain  hemorrhagic 
fluid,  should  be  looked  upon  as  carcinomatous  unless  there  is  an 
intracystic  papilloma  to  account  for  the  blood. 

Treatment  consists  in  radical  operation  as  for  other  forms  of  car- 
cinoma. 

Extension  of  Mammary  Carcinoma. — Local  extension  occurs  especially 
to  the  overlying  skin,  to  all  portions  of  the  mammary  gland  and  its 
ramifications,  and  to  the  sur- 
rounding adipose  tissue.  The 
deep  fascia  overlying  the  pec- 
toral muscles  and  as  far  down 
as  the  epigastrium  is  widely 
infiltrated,  and  early  invasion 
of  the  pectoralis  major  muscle 
may  occur,  as  demonstrated  by 
Heidenhain  (1889). 

Lymphatic  extensions  are  di- 
rectly continuous  with  the  main 
growth  by  fine  columns  of  cancer 
cells.  As  the  primary  tumor  in 
most  cases  is  in  the  upper  outer 
quadrant  it  is  the  axillary  lym- 
phatics that  are  first  invaded  as 
a  rule,  and  this  invasion  occurs 
long  before  the  nodules  are  pal- 
pable. In  most  cases  the  nodes 
which  first  become  palpable  are 

those  on  the  side  of  the  thorax,  about  midway  between  the  axillary 
folds.  Let  the  patient's  arm  hang  by  her  side,  so  as  to  relax  the 
axillary  fascia,  and  then  palpate  gently  and  attentively  in  this  region. 
But  in  the  case  of  a  growth  in  the  extreme  upper  and  outer  part  of 
the  gland,  early  extension  may  occur  to  the  nodes  highest  in  the 
axilla,  and  these  rarely  can  be  palpated.  In  time  all  the  axillary 
lymphatics  are  involved,  and  even  the  supraclavicular  nodes  may 
become  enlarged.  In  advanced  cases  lymphedema  of  the  arm  results 
from  the  axillary  lymphatic  obstruction;  venous  obstruction  may  also 
contribute  to  the  edema;  and  pain  from  compression  of  the  axillary 
nerves  may  be  a  very  distressing  symptom.  Lymphatic  extension 
49 


Fig.  825. — Lymphatics  of  the  breast  and 
axilla,  involved  in  mammary  carcinoma. 
Episcopal  Hospital. 


770  SURGERY  OF  THE  BREAST 

may  also  occur  to  the  mediastinum,  especially  if  the  tumor  grows 
in  one  of  the  inner  quadrants  of  the  breast;  or  extension  may  occur 
across  the  middle  line  of  the  body  to  the  other  breast,  or  even  to 
the  other  axilla.  Both  breasts  and  both  axillae  always  should  be 
examined  attentively.  Finally  reference  must  be  made  again  to 
cancer  en  cuirasse,  due  to  widespread  carcinomatous  lymphangeitis 
of  the  skin. 

Distant  metastases  by  way  of  the  blood-stream  are  denied  by  modern 
pathologists.  Cancer  cells  in  the  blood  excite  thrombosis,  and  the 
thrombus  as  it  organizes  usually  destroys  or  renders  them  harmless 
(Handley).  Handley  has  also  indicated  that  bone  lesions  (confined 
to  the  bones  of  the  trunk,  the  proximal  ends  of  the  limbs,  and  the 
skull)  are  or  have  been  in  direct  continuity  with  the  main  growth; 
their  site  often  is  suggested  by  the  presence  of  subcutaneous  nodules 
over  the  affected  bone,  even  before  bone  pains,  or  pathological  fracture 
demonstrate  their  existence.  In  cases  of  scirrhus  this  sad  event  occa- 
sionally occurs  before  the  local  tumor  is  noted;  and  it  is  a  rule 
always  to  consider  the  possibility  of  already  present  metastases  before 
operating  on  a  case  of  scirrhus,  and  always  to  inquire  into  the  con- 
dition of  the  mammary  gland  in  the  case  of  obscure  malignant  growths 
in  the  bones  or  viscera. 

Radical  Operation  for  Mammary  Carcinoma. — Ablation  of  the  Breast. — 
The  general  principles  on  which  a  radical  operation  for  malignant 
disease  is  based  were  discussed  in  Chapter  IV  (p.  132).  The  develop- 
ment of  the  technique  of  the  modern  operation  for  carcinoma  of  the 
breast  is  due  largely  to  the  teaching  of  C.  H.  Moore,  Volkmann, 
Heidenhain,  Stiles,  Halsted,  and  Handley.  Moore  (1867)  was  one 
of  the  earliest  to  discard  the  theory  of  a  cancerous  diathesis,  and  to 
look  upon  it  as  a  disease  of  purely  local  origin;  in  consequence  he 
urged  wide  excision  of  the  breast  and  all  involved  structures  (pectoral 
fascia  and  muscle  and  enlarged  lymphatics)  in  one  mass.  Volkmann 
(1875)  always  excised  the  pectoral  fascia  and  emphasized  the  necessity 
of  removing  the  surface  of  the  pectoral  muscles  when  diseased,  and 
established  the  "three  year  limit,"  all  patients  free  from  recurrence 
after  this  interval  being  reckoned  as  "cures."  Though  recurrences 
(or  perhaps  new  carcinomas)  may  grow  after  intervals  of  ten  and 
even  twenty  or  more  years,  it  is  found  by  the  best  operators  today 
that  recurrence  after  a  free  interval  of  three  years  occurs  in  only 
about  20  per  cent,  of  patients.  Heidenhain  (1889)  urged  removal 
of  the  surface  of  the  pectoral  is  major  muscle  in  all  cases,  even  when 
not  visibly  diseased,  as  on  microscopic  examination  he  found  it  always 
invaded  by  cancer  cells.  Stiles  (1892)  called  renewed  attention  to 
the  importance  of  wride  local  excision,  showing  the  great  area  over 
which  the  mammary  gland  was  spread  out- — sending  processes  to  the 
clavicle  above,  to  the  axilla  laterally,  and  well  below  the  lower  border 
of  the  pectoralis  major,  on  to  the  serratus  magnus,  rectus,  and  external 
oblique  muscles.  Halsted  (1894)  introduced  removal  of  the  pectoralis 
major  as  a  measure  of  routine,  to  facilitate  clearing  the  axilla,  in 


RADICAL  OPERATION  FOR  MAMMARY  CARCINOMA        771 


every  case,  whether  the  axilla  was  manifestly  diseased  or  not;  and  he 
also  insisted  that  the  supraclavicular  lymph  nodes  should  be  excised, 
and  that  the  entire  diseased  tissue  should  be  removed  in  one  piece. 
Willy  Meyer  in  the  same  year  urged  removal  of  the  pectoralis  minor 
in  every  case,  and  renewed  the  advice  of  Gerster  (1885),  who  had 
advocated  commencing  the  operation  by  the  axillary  dissection, 
which  was  left  by  others  for  the  last  step,  and  usually  was  under- 
taken only  after  the  main  tumor  mass  had  been  cut  away.  Finally, 
Handley,  in  his  Astley  Cooper  prize  essay  (1905),  demonstrated 
anew  the  importance  of  the  deep  fascia  as  the  main  highway  by  which 
the  carcinoma  cells  spread  in  all  directions  from  the  common  center 
of  disease,  and  should  the  necessity  of  removing  it  in  a  wide  circle  on  all 
sides  of  the  growth,  which  should  be  taken  as  a  center.  This  excision 
extends  laterally  to  the  latissimus  dorsi,  medially  well  beyond  the 
middle  line,  and  inferiorly,  at  least  two  inches  below  the  ensiform 
process. 

The  operation  thus  comprises  removal  of  a  very  wide  area  of  skin, 
the  mammary  gland  with  surrounding  fat,  the  deep  fascia,  both 
pectoral  muscles,  and  axillary 
lymphatics,  in  one  mass.  If  this 
diseased  mass  is  cut  into  at  any 
point  the  contained  cancer  cells 
will  be  given  a  chance  to  escape 
into  the  surrounding  healthy  tis- 
sues, and  recurrence  will  be  very 
apt  to  follow.  For  the  same 
reason  all  rough  handling  and  tear- 
ing the  tissues  apart  by  blunt 
dissection  should  be  avoided. 

Skin  Incision. — So  long  as  this 
removes  a  sufficient  area  of  skin, 
its  particular  form  is  immaterial. 
A  wound  which  cannot  be  closed 
completely  is  less  likely  to  be  the 
seat  of  recurrence  than  one  which 
can,  because  there  is  less  likeli- 
hood of  diseased  tissue  remaining. 
I  prefer  Jabez  N.  Jackson's  (Fig. 
826)  incision  (1906)  for  early  cases 
with  little  apparent  involvement  of  the  skin. 
Rodman's  incision  is  as  good  as  any  (Fig.  827) 


Fig.  826. — Jackson's  incision  for  carci- 
noma of  the  breast,  suitable  for  early 
cases.  The  rectangular  flap  is  turned  down- 
ward and  the  axillary  flap  upward  in 
closing  the  wound.       Episcopal  Hospital. 


For  the  average  case 
Only  a  portion  of  the 
incision  is  made  at  first,  sufficient  for  the  dissection  of  the  axilla, 
which  should  constitute  the  first  step  in  the  operation.  To  postpone 
this  to  the  last,  as  in  Halsted's  method,  leaves  the  entire  thoracic 
wound  exposed  during  the  most  tedious  part  of  the  operation;  whereas, 
if  the  axilla  is  cleared  first  (and  this  may  require  two  hours  or  more 
in  difficult  cases)  the  remainder  of  the  operation  may  be  completed 
in  about  fifteen  minutes.     Moreover,  the  blood-supply  is  controlled 


772 


SURGERY  OF  THE  BREAST 


much  more  effectively  if  each  branch  going  to  the  tumor  mass  is 
secured  at  its  origin. 

The  pectoral  is  major  muscle  is  exposed  first,  its  upper  border 
identified,   clamping  or  protecting  the   cephalic  vein.     A  finger   is 

then  passed  beneath  the  muscle, 
and  it  is  divided  close  to  its 
humeral  attachment.  The  cla- 
vicular fibers  of  the  pectoralis 
major  are  next  cut  close  to  the 
bone.  This  exposes  the  pector- 
alis minor,  which  is  similarly 
divided  close  to  the  coracoid 
process,  and  the  axilla  is  fully 
exposed.  If  there  are  palpably 
enlarged  lymph  nodes  at  the  apex 
of  the  axilla,  the  skin  incision 
should  be  extended  upward 
across  the  clavicle,  and  the 
supraclavicular  nodes  explored. 
If  enlarged  they  should  be  re- 
moved. Unfortunately  it  is  not 
feasible  to  remove  them  in  one 
mass  with  the  axillary  lymph- 
atics, and  they  must  be  excised 
separately.  Then  the  axilla  is 
cleared  from  above  downward, 
working  along  the  axillary  vessels 
to  the  lower  border  of  the  latis- 
simus  dorsi.  Arterial  and  venous  branches  are  clamped  and  cut  close 
to  the  main  trunks.  Whenever  the  supply  of  hemostats  is  exhausted, 
all  clamped  points  should  be  ligated,  thus  releasing  the  hemostats  for 
future  use.  The  main  nerve  trunks  are  carefully  preserved,  as  is  the 
median  (long)  subscapular  nerve  which  supplies  the  latissimus  dorsi; 
injury  to  this  will  affect  the  usefulness  of  the  arm.  Sensory  nerves 
may  be  cut  without  compunction.  When  the  vessels  once  have  been 
dissected  free  the  operation  may  proceed  with  greater  rapidity.  The 
entire  axillary  contents  are  turned  toward  the  chest,  and  the  lateral 
thoracic  wall,  from  behind  forward,  is  denuded  of  fascia;  here  the  long 
thoracic  nerve  (external  respiratory)  should  be  looked  for  and  pre- 
served.    The  axillary  wound  is  then  filled  with  gauze. 

The  skin  incisions  are  gradually  extended  to  outline  the  breast, 
and  are  extensively  undermined,  on  all  sides,  leaving  attached  to 
them  only  enough  superficial  fat  to  prevent  sloughing.  The  axillary 
contents  and  pectoral  muscles  are  then  turned  toward  the  median 
line,  and  the  dissection  of  the  chest  is  continued  from  the  lateral 
wall  to  the  sternum.  Here  the  perforating  branches  of  the  intercostals 
and  internal  mammary  arteries  will  be  encountered,  and  may  cause 
troublesome   bleeding   if   allowed   to   retract   below  the   intercostal 


Fig.  827. — Rodman's  incision  for  carci- 
noma of  the  breast,  suitable  for  most 
cases.  The  triangular  flap  below  the 
clavicle  is  pulled  downward,  and  the  under- 
mined skin  on  the  lateral  surface  of  the 
thorax  is  pulled  upward,  the  wound  being 
sutured  in  the  form  of  the  letter  T,  the 
long  limb  lying  in  the  long  axis  of  the 
breast.    Episcopal  Hospital. 


RADICAL  OPERATION  FOR  MAMMARY  CARCINOMA       773 

muscles  before  being  clamped.  The  tumor  mass  now  being  free  above, 
the  dissection  is  continued  downward,  removing  the  deep  fascia  over 
the  upper  portion  of  the  rectus  muscle  in  the  epigastric  region. 

The  tumor  being  thus  removed,  a  puncture  for  drainage  is  made 
in  the  skin  of  the  axilla,  and  a  tube  introduced;  which  is  allowed  to 
remain  four  or  five  days.  The  skin  is  then  sutured,  closing  the  wound 
as  far  as  can  be  done  without  undue  tension.  The  arm  is  dressed  in 
a  fully  abducted  position;  this  permits  more  accurate  apposition  of 
the  skin  to  the  axilla,  prevents  accumulation  of  wound  discharges 
here,  and  facilitates  return  of  the  function  of  the  upper  extremity. 
When  the  skin  is  accurately  adjusted  to  support  the  axillary  struc- 
tures, it  is  very  seldom  that  disability  follows  from  cicatricial  con- 


Fig.  828. — Ablation  of  the  breast:  the  pectoralis  major  has  been  cut  near  its  humeral 
insertion,  and  its  clavicular  fibers  have  been  divided,  exposing  the  pectoralis  minor. 
The  entire  skin  incision  (indicated  in  the  drawing)  is  not  made  at  one  time,  but  only 
as  the  operation  proceeds. 


traction.  Lymphedema  may  develop  after  the  operation,  especially 
when  a  thorough  removal  of  the  axillary  lymphatics  has  been  accom- 
plished. It  may  be  treated  by  Handley's  operation  (p.  301).  Excel- 
lent motion  is  retained  by  the  arm  in  spite  of  removal  of  both  pectoral 
muscles,  and  the  patient  is  little  if  at  all  inconvenienced  by  their  loss. 

The  immediate  mortality  of  the  extensive  operation  described  above 
is  very  low — not  more  than  1  per  cent,  in  skilled  hands.  Deaths  are 
caused  almost  solely  by  visceral  complications,  such  as  pneumonia, 
cardiac  disease,  or  uremia. 

After-treatment. — When  the  incision  cannot  be  sutured  completely, 
some  surgeons  prefer  to  do  skin-grafting  at  the  conclusion  of  the 
operation;  while  others  postpone  this  until  granulation  has  commenced. 
Personally  I  believe  it  is  better  to  do  neither,  but  to  expose  the  granu- 
lating surface  to  the  a>ray  at  suitable  intervals.  If  this  treatment  is 
conducted  by  a  skilled  rontgenologist,  there  seems  much  less  tendency 
to  recurrence,  and  where  inoperable  recurrence  takes  place  this  treat- 
ment greatly  relieves  the  pain,  diminishes  the  discharge  and  fetor, 
and  keeps  the  patients  comfortable  (Figs.  820  and  824). 


774  SURGERY  OF  THE  BREAST 

Examination  of  the  wound  for  recurrence  should  be  insisted  upon, 
at  first  monthly;  then  every  three  or  four  months,  until  the  three 
year  period  has  elapsed.  After  this  time  the  patient  should  report 
to  her  surgeon  at  least  once  a  year,  or  immediately  if  any  symptoms 
arise. 

End  Results  of  the  Radical  Operation  for  Carcinoma  of  the  Breast. — 
If  the  operation  is  done  in  favorable  cases  (before  there  is  palpable 
axillary  involvement  and  before  the  tumor  is  fixed  or  the  overlying 
skin  ulcerated),  about  70  per  cent,  of  patients  will  be  "cured"  in 
Volkmann's  sense;  that  is,  they  will  remain  free  of  recurrence  for  a 
period  of  three  years.  And  of  these  clinical  "cures,"  only  about  one- 
fifth  will  have  a  recurrence  at  a  later  date.  If  axillary  invasion  has 
occurred  before  the  operation  is  done,  about  25  per  cent,  of  patients 
will  be  in  good  health  after  three  years.  These  figures  are  conserva- 
tive, as  better  results  are  reported  by  those  who  do  most  of  these 
operations. 

But  the  advantages  of  the  operation  are  great  even  if  recurrence 
or  metastasis  eventually  occurs.  At  the  very  worst,  the  patient 
will  enjoy  a  number  of  months,  perhaps  several  years,  of  good  health, 
and  will  have  hope  of  ultimate  cure.  Even  if  recurrence  takes  place 
a  cure  may  still  be  possible  by  aid  of  a  second  or  third  operation. 
Finally,  if  metastasis  occurs,  and  death  results  from  this  cause,  it 
will  be  a  very  much  less  painful  death  than  that  from  local  recurrence, 
and  the  operation  at  least  will  have  prolonged  life  and  afforded  an 
interval  of  comfort  and  of  hope. 

Inoperable  Cases. — Usually  no  operation  should  be  undertaken 
in  cases  in  which  it  is  manifestly  impossible  to  remove  all  of  the 
disease.  In  most  patients  with  the  supraclavicular  nodes  palpably 
enlarged,  no  operation,  however  radical,  will  effect  a  cure;  but  if 
the  tumor  is  not  otherwise  inoperable,  the  radical  operation  may  be 
done,  these  nodes  being  removed  at  a  second  operation  ten  days  or 
two  weeks  later.  Only  if  they  are  very  slightly  involved  is  it  safe 
to  prolong  the  original  operation  for  their  immediate  removal. 

Recurrences  are  to  be  treated  on  the  same  principles  as  the  primary 
growth.  Even  fixation  to  the  chest  wall  does  not  necessarily  contra- 
indicate  excision;  the  portions  of  ribs  invaded  may  be  removed. 

Palliative  operations  sometimes  are  done  in  inoperable  cases.  Very 
occasionally  mere  "amputation'"  of  the  breast  (p.  759),  to  remove 
a  sloughing  ulcer,  followed  by  a;-ray  treatment,  will  promote  the 
patient's  comfort  and  prolong  life  even  when  cure  is  out  of  the  question 
(Fig.  820) .  Cauterization  with  the  actual  cautery,  or  with  chemicals, 
such  as  chloride  of  zinc  solution  (5  per  cent.),  sometimes  will  relieve 
discomfort  by  sterilizing  the  surface  of  a  sloughing  growth.  Double 
oophorectomy,  introduced  by  Beatson  of  Glasgow,  in  1896,  has  been 
employed  in  a  number  of  advanced  cases,  and  in  some  patients  shrink- 
age of  the  breast  tumor  and  considerable  relief  has  followed.  Ampu- 
tation at  the  shoulder-joint  was  employed  by  Esmarch  (1883)  as  a 
primary  operation  in  one  far  advanced  case,  and  has  been  practised 


INJURIES 


775 


a  number  of  times  since  in  cases  of  recurrence;  and  even  interscapulo- 
thoracic  amputation  has  been  employed  in  cases  of  recurrence  (Dent, 
in  1897,  and  later  by  others).  Others  have  employed  rhizotomy 
(p.  573),  with  marked  relief  of  pain. 


SURGERY  OF  THE  CHEST  WALL. 

Congenital  and  Acquired  Malformations. — These  are  of  interest 
from  a  diagnostic  point  of  view,  but  little  can  be  done  in  the  way 
of  treatment.  Birth  injuries  occasionally  result  in  deformities  which 
persist  through  adult  life  (Fig.  829),  but  seldom  entail  any  disability. 
The  diagnosis  is  made  from  the  history.    Rachitic  deformities,  reference 


Fig.  829. — Birth  injury  of  thorax. 
Orthopaedic  Hospital. 


Fig.  830. — Funnel  breast   (rachitic). 
Orthopaedic  Hospital. 


to  which  was  made  at  p.  456,  develop  during  infancy  or  early  child- 
hood, and  are  recognized  by  coincident  symptoms  of  rachitis.  The 
most  frequent  deformities  are  the  "rachitic  rosary,"  Harrison's 
groove,  and  pigeon  breast;  these  seldom  persist  past  the  age  of 
puberty.    Funnel  breast,  however,  may  last  through  life  (Fig.  830). 

Some  of  these  deformities  may  be  improved  by  gymnastic  exercises, 
or  by  the  use  of  orthopedic  apparatus,  if  treatment  is  begun  in  early 
childhood;  but  the  disability  is  so  slight  in  adult  life  that  no  active 
interference  is  required. 

Injuries. — The  most  frequent  injury  is  fracture  of  the  ribs.  This 
was  considered  at  p.  359.  Simple  contusions  require  no  special 
notice.     Severe  lacerated  wounds,  with  compound  fracture  of  the 


77G 


SCL'dEh'Y   OF   THE  CHEST   WALL 


ribs,  usually  are  attended  by  visceral  injuries  (for  which  see  p.  783). 

They  are  caused  by  crushing  injuries,  explosions,  etc.,  and  often  are 

fatal.  If  the  patient  survives,  con- 
valescence is  prolonged,  and  severe 
deformity  may  ensue   (Fig.  831). 

In  some  cases  a  phenomenon 
known  as  traumatic  asphyxia,  or 
stasis  cyanosis,  follows  sudden  vio- 
lent compression  of  the  chest  (or 
abdomen)  of  short  duration.  This 
state  is  characterized  by  marked 
cyanosis  of  the  head,  face,  and 
neck,    usually    sharply    delimited    a 


"THBHP 

\ 

*^M    MM   m 

^*h^ 

Fig.  831. — Deformity  of  thorax 
following  injury  by  explosion  in 
coal  mine.    Episcopal  Hospital. 


Fig.  832. — Traumatic  asphyxia;  oxygen  in- 
halations. Death  in  twelve  hours.  Episcopal 
Hospital. 


short  distance  above  the  clavicle,  apparently  by  the  collar.  The 
patient  looks  as  if  he  had  been  strangled  (Fig.  832):  the  eyes  are 
bloodshot,  and  the  eye-lids  may  become  edematous;  there  may  be 
hemorrhages  from  the  naso-pharynx  or  ears;  convulsion's  or  uncon- 
sciousness may  occur.  In  addition  to  shock,  there  is  irregularity 
or  entire  failure  of  respiration.  The  cyanosis,  which  is  petechial  in 
appearance,  may  be  due  to  extravasation  of  blood  (true  traumatic 
asphyxia)  or  to  dilatation  of  the  capillaries  with  blood  stasis  (stasis 
cyanosis) .  It  is  difficult  to  differentiate  the  conditions,  which,  indeed, 
often  coexist.  The  mechanism  by  which  this  state  is  produced  is 
believed  to  be  sudden  compression  of  the  thorax  with  the  glottis 
closed,  causing  violent  reflux  of  blood  from  the  right  heart.  There 
may  be  interstitial  and  subpleural  hemorrhages  in  the  lungs,  with 
interstitial  emphysema;  and  in  some  cases  cerebral  congestion  and 
hemorrhages  have  been  found  postmortem. 

Treatment. — Treatment  comprises  measures  to  overcome  shock, 
with  artificial  respiration,  and  inhalations  of  oxygen. 

Surgical  Emphysema. — Surgical  emphysema  is  a  term  used  to 
describe  the  escape  of  air  into  the  subcutaneous  tissues.  As  previously 
noted  (p.  334)  it  may  occur  in  the  face  in  connection  with  fractures 


AXILLARY  ABSCESS  111 

of  the  nose,  etc.  The  most  usual  form,  however,  is  that  due  to  thoracic 
injury;  and  the  air  escapes  across  the  pleura  from  the  lungs  which 
have  been  punctured  by  a  broken  rib  or  ruptured  by  the  compressing 
force.  If  the  emphysema  appears  first  at  the  root  of  the  neck,  and 
not  at  the  site  of  injury,  it  is  probable  that  the  rupture  of  the  lung 
is  entirely  subpleural,  and  that  the  air  has  escaped  into  the  loose 
cellular  tissues  surrounding  the  bronchi,  and  eventually  reaches  the 
neck  by  way  of  the  mediastinum.  This  subcutaneous  emphysema 
may  occur  without  any  clinical  evidence  of  severe  intra-thoracic 
injury,  but  as  auscultation  and  percussion  are  much  interfered  with 
by  its  development,  it  is  probable  that  the  deeper  lesions  often  are 
overlooked.  Occasionally  a  wound  of  the  pleura,  without  injury  of 
the  lung,  may  cause  the  development  of  emphysema,  the  outside  air 
being  sucked  into  the  wound  by  the  negative  intra-thoracic  pressure. 

The  air  may  spread  far  over  the  body,  up  to  the  scalp,  down  to 
the  groin,  and  even  out  along  the  limbs;  the  eyes  may  be  closed  up, 
and  the  patient  may  become  so  bloated  that  recognition  will  be 
impossible.  Subjective  symptoms,  except  those  due  to  visceral 
lesions,  are  insignificant.  Palpation  of  the  areas  affected  produces 
typical  crackling;  the  skin  feels  as  if  floated  up  from  the  muscles  or 
bones  by  an  effervescing  liquid;  the  air  may  be  driven  from  one 
place  to  another  by  the  fingers,  and  pitting  on  pressure  is  apparent. 
The  larger  the  source  of  supply,  the  more  rapid  will  be  the  develop- 
ment and  spread  of  the  emphysema.  In  some  cases  only  a  very 
limited  area  is  affected,  and  attentive  examination  is  required  to 
detect  it;  in  others  the  emphysematous  area  increases  rapidly  in  size 
as  the  patient  is  watched. 

Treatment. — Mild  cases  require  no  treatment;  but  usually,  whether 
or  not  there  is  fracture  of  the  ribs,  the  injured  side  of  the  thorax 
should  be  strapped,  as  limitation  of  the  respiratory  excursions  will 
diminish  the  spread  of  the  air.  Where  the  emphysema  is  very  marked, 
it  has  been  recommended  that  multiple  punctures  be  made  with  a 
fine  pointed  bistoury,  or  tenotome,  whereupon  air  will  escape  with 
a  hissing  noise,  and  the  swelling  will  partly  subside.  As  a  matter  of 
fact,  if  any  treatment  is  necessary,  it  is  much  better  to  aspirate  the 
pneumothorax,  since  as  long  as  this  continues  air  will  escape  from  it 
into  the  subcutaneous  tissues.  The  chief  danger  is  infection  of  the 
subcutaneous  tissues,  with  widespread  cellulitis.  Apart  from  this  and 
visceral  lesions,  the  prognosis  is  good. 

Axillary  Abscess. — This  may  be  superficial  or  deep.  The  former, 
which  is  more  frequent  and  less  serious,  arises  in  connection  with  the 
hair  follicles  or  sebaceous  glands,  as  a  furunculosis;  the  process  occurs 
superficially  to  the  axillary  fascia.  Usually  suppuration  starts  in 
several  different  points,  but  if  incision  is  not  made  promptly  these 
may  coalesce  to  form  one  abscess  (Fig.  833).  Treatment  consists  in 
incision  and  drainage. 

Deep  or  True  Axillary  Abscess  arises  in  the  tissues  of  the  axilla 
underneath  the  axillary  fascia;  it  begins  as  lymphadenitis  (Fig.  834), 


77.s 


SURGERY  OF  THE  CHEST  WALL 


and  usually  is  due  to  a  primary  infection  in  the  hand,  or  rarely  in 
the  breast.  Occasionally  these  deep  axillary  abscesses  point  through 
the  thin  (cribriform)  portions  of  the  axillary  fascia  and  present 
beneath  the  skin.  Rarely  the  pus  may  travel  upward  along  the  sheath 
of  the  axillary  vessels  and  point  at  the  root  of  the  neck.  Owing  to  the 
deep  seat  of  the  inflammation,  and  to  the  pus  being  covered  by  the 
dense  axillary  fascia,  distinct  evidences  of  suppuration  often  are 
absent.  The  surgeon  should  not  wait  for  fluctuation,  or  even  for 
redness  and  edema  of  the  overlying  skin,  or  other  classical  signs  of 
abscess.  The  subjective  symptoms,  pain,  tenderness,  and  loss  of 
function  of  the  arm,  are  so  severe  as  to  suggest  serious  trouble,  and 
the  constitutional  evidences  of  infection  may  be  marked.  Therefore 
no  time  should  be  lost  in  draining  the  axilla.  Usually  an  anesthetic 
is  desirable.    An  incision  is  made  from  the  outer  border  of  the  axilla 


Fig.    833.— Abscess  superficial    to   deep 
fascia  of  axilla.     Episcopal  Hospital. 


Fig.  834. — Deep  axillary  abscess, 
following  lymphadenitis;  duration  six 
weeks.     Episcopal  Hospital. 


inward  to  the  chest  wall,  midway  between  the  anterior  and  posterior 
axillary  folds.  After  the  skin  is  incised  the  knife  should  be  kept 
fairly  close  to  the  thorax.  When  the  axillary  fascia  has  been  incised, 
if  pus  does  not  flow,  further  exploration  should  be  conducted  accord- 
ing to  Hilton's  method  (p.  50).  The  axilla  is  drained  by  a  tube,  and 
the  arm  is  carried  in  a  sling. 

Subpectoral  Abscess. — This  is  an  abscess  between  the  pectoralis 
major  muscle  and  the  pectoralis  minor,  or  one  beneath  the  latter 
muscle,  at  the  extreme  apex  of  the  axilla.  Probably  in  most  cases 
it  is  caused  by  direct  contusion  or  strain  of  the  pectoral  muscle, 
producing  a  small  hematoma  which  subsequently  is  infected  through 
the  blood-stream.  It  may  arise  in  suppuration  of  the  subclavian 
lymph  nodes,  which  lie  on  the  anterior  surface  of  the  pectoralis  minor 
or  clavipectoral  fascia.     Sometimes  this  follows  infected  wounds  of 


SUBSCAPULAR  ABSCESS 


779 


the  extensor  surfaces  of  the  fingers  or  forearm,  since  the  lymphatics 
from  these  regions  may  pass  directly  to  these  nodes  along  the  cephalic 
vein;  whereas  the  lymphatics  from  other  regions  of  the  hand  and  fore- 
arm enter  the  axilla  with  the  brachial  vessels.  Rarely  a  subpectoral 
abscess  is  caused  by  caries  of  the  ribs,  or  by  bronchial  or  pleural  infec- 
tion; in  such  cases  the  abscess  often  is  chronic  and  is  due  to  tuber- 
culosis (Fig.  841). 


Fig.  835. — Right  subpectoral  ab- 
scess; duration  three  weeks.  No 
cause  discoverable.  Episcopal  Hos- 
pital. 


Fig.  836. — Abscess  in  left  supraspinous 
fossa;  duration  one  week;  cause  unknown. 
Incision  evacuated  200-250  c.c.  of  pus.  Healed 
in  six  days.    Episcopal  Hospital. 


Symptoms. — A  subpectoral  abscess  forms  a  rounded,  tender,  painful 
swelling  below  the  inner  part  of  the  clavicle;  it  tends  to  point  at  the 
lower  border  of  the  pectoralis  major  (Fig.  835),  or  rarely  may  burrow 
through  an  intercostal  space  into  the  pleura.  It  is  differentiated  from 
axillary  abscess  by  its  position  nearer  the  median  line  of  the  body, 
and  by  the  relaxed  condition  of  the  axillary  fascia  and  freedom  of  the 
axilla;  and  from  arthritis  of  the  shoulder  by  the  slight  impairment 
of  the  movements  of  the  joint,  which  are  quite  free  within  a  limited 
range.  I  have  seen  the  condition  mistaken  for  tuberculosis  of  the 
shoulder-joint. 

Treatment. — The  abscess  should  be  opened  by  an  incision  along 
the  lower  border  of  the  pectoralis  major,  and  should  be  drained  with 
a  tube.    Musser  collected  23  cases  with  13  deaths. 

Subscapular  Abscess. — This  is  quite  rare.  It  may  follow  disease  of 
the  scapula  or  shoulder-joint.  The  pus  forms  in  the  space  between 
the  serratus  magnus  and  the  posterior  thoracic  wall.  It  cannot  point 
anteriorly  because  of  the  attachment  of  the  serratus  magnus  to  the 
lateral  aspect  of  the  thorax;  it  cannot  escape  internally  because  of  the 


7S0 


SURGERY  OF  THE  CHEST  WALL 


spinal  connections  of  the  scapula.  The  pus,  therefore,  spreads  either 
upward,  and  points  beneath  the  trapezius,  which  is  unusual;  or  down- 
ward to  the  angle  of  the  scapula. 

If  the  existence  of  this  condition  is  remembered,  the  diagnosis 
rarely  will  be  difficult.  The  abscess  should  be  opened  at  the  lower 
angle  of  the  scapula,  and  drained.  In  some  cases  the  body  of  the 
bone  may  be  trephined. 

Suprascapular  Abscess. — Suppuration  in  the  supraspinous  fossa  is 
another  unusual  condition  (Fig.  836).  Unless  the  condition  is  borne 
in  mind,  the  swelling  may  be  mistaken  for  a  sarcoma.  The  onset 
usually  is  subacute,  and  may  follow  the  formation  of  a  hematoma  in 
the  supraspinatus  muscle  as  the  result  of  trauma;  or  the  lesion  may 
be  tuberculous  and  arise  in  the  bone.    The  abscess  should  be  opened 

and  drained,  unless  it  is  thought 
to  be  tuberculous,  when  it  should 
be  treated  as  a  tuberculous  ab- 
scess elsewhere  in  the  body  (p. 
526). 

Caries  of  the  Ribs  and  Costal 
Cartilages.  —  This  usually  is 
tuberculous  in  nature.  It  may 
be  due  to  extension  from  a  focus 
in  the  vertebrae,  or  from  a  tuber- 
culous pleurisy;  or  the  disease 
may  be  primary  in  the  ribs.  In 
the  latter  case  development  of 
the  affection  often  follows  in- 
jury. Usually  the  patients  are 
adults,  and  there  often  is  pul- 
monary tuberculosis  or  a  tuber- 
culous lesion  in  the  bones,  joints, 
or  lymph  nodes.  Early  forma- 
tion of  a  cold  abscess  occurs,  and 
this  presents  itself  as  a  fusiform 
swelling  along  the  course  of  one 
or  more  of  the  ribs.  The  ribs 
from  the  third  to  the  eighth  are  oftenest  affected,  near  the  chondral 
or  the  vertebral  joints.  The  disastrous  results  of  spontaneous  fistu- 
lization  and  secondary  infection  are  as  prominent  here  as  elsewhere 
in  the  body  where  tuberculous  disease  is  concerned;  and  owing  to  the 
susceptibility  of  cartilage  to  infection,  owing  to  its  lack  of  blood  supply 
(Axhausen,  1913),  interminable  suppuration  ensues,  with  numerous 
fistulse,  and  constant  pocketing  of  "hot"  pus,  which  requires  evacua- 
tion (Fig.  837) .  Permanent  cure  can  be  secured  only  by  radical  extir- 
pation of  all  cartilage  which  has  been  denuded  of  perichondrium 
(Moschcowitz,  1918) :  though  the  tuberculous  infection  may  be  eradi- 
cated by  the  first  operation,  pyogenic  cocci  continue  to  invade  damaged 
cartilage,  which  should  be  excised  until  cancellous  bone  is  reached  at 


Fig.  837. — Extensive  scars  of  both  hyper- 
chondriac  regions  from  previous  operations 
for  necrosis  of  ribs.     Episcopal  Hospital. 


ACUTE  MEDIASTINI TIS 


781 


both  ends.  If  seen  before  rupture  occurs,  the  abscess  should  receive 
the  treatment  advised  for  cold  abscess  in  general  (p.  526). 

Tuberculosis  may  also  affect  the  joints  of  the  sternum;  at  the 
junction  of  the  manubrium  and  gladiolus  its  development  has  been 
mistaken  for  fracture  (N.  B.  Carson). 

Acute  septic  osteomyelitis  of  the  ribs  may  occur,  but  is  rare;  also 
rare  is  typhoid  periosteitis  of  the  ribs,  which  may  not  develop  for 
months  or  years  after  the  attack  of  typhoid  fever.  Osteomyelitis 
may  result  in  necrosis  of  the  ribs,  and  resection  of  the  portions  affected 
may  be  required;  in  cases  of  typhoid  origin,  however,  curettement 
of  the  carious  surfaces  usually  is  sufficient. 


SURGERY  OF  THE  ANTERIOR  MEDIASTINUM. 

Acute  Mediastinitis. — Acute  mediastinitis  is  the  term  used  for  a 
cellulitis  of  the  mediastinum.  It  may  follow  a  stab  or  gunshot  wound, 
or  may  result  from  extension  downward  of  a  cervical  cellulitis  or  be 
secondary  to  a  pulmonary  lesion.  I  have  seen  a  metastatic  abscess  in  the 
mediastinum  in  a  case  of  osteomye- 
litis of  the  femur.  There  are  pain, 
tenderness  on  pressure  over  the 
sternum,  and  constitutional  symp- 
toms of  sepsis.  Signs  of  cardiac, 
pulmonary,  or  tracheal  compression 
may  arise.  Usually  in  the  course 
of  time  pus  is  formed,  and  this  seeks 
an  exit  for  itself  through  an  inter- 
costal space  close  to  the  sternum, 
or  possibly  by  rupture  into  a  bron- 
chial tube  or  the  pleura.  Subcuta- 
neous emphysema  may  be  an  early 
sign.  Lymphadenitis  of  the  medias- 
tinum usually  is  tuberculous.  The 
onset  of  symptoms  is  less  acute  than 
in  mediastinitis. 

Treatment. — When  medical  meas- 
ures, with  cold  locally,  fail  to  relieve 
the  symptoms,  and  especially  when 
symptoms  of  respiratory  obstruc- 
tion arise,  surgical  intervention  is 
called  for,  even  before  pointing  of 
an  abscess  occurs.  The  operation 
consists  in  trephining  the  sternum, 
enlarging  the  opening  with  rongeur 
forceps,  and  evacuating  the  pus  by 
Hilton's  method  (p.  50).  An  ab- 
scess may  be  opened  where  it  points,  but  even  then  it  is  usually 
necessary  to  cut  away  part  of  the  sternum  to  secure  free  drainage. 


Fig.  838. — Abscess  of  the  mediastinum 
in  a  patient  aged  fifty-two  years.  Dura- 
tion three  weeks,  following  influenza.  In- 
cision evacuated  pus  and  air.  Recovery. 
Episcopal  Hospital. 


782  SURGERY  OF  THE  LUNGS  AND  PLEURA 

Mediastinal  Tumors. — These  give  evidence  of  their  presence  by 
compression  symptoms,  and  by  an  abnormal  area  of  dulness  on 
percussion.  Tuberculous  lymphadenitis  is  the  most  frequent  non- 
neoplastic growth.  The  lymphadenoid  enlargements  of  Hodgkin's 
disease  and  sarcoma  are  not  so  frequent  as  secondary  deposits  of 
carcinoma.  Benign  tumors,  especially  dermoids,  also  occur.  As  a 
rule  no  surgical  treatment  offers  any  prospect  of  cure;  but  palliation 
may  be  offered  by  splitting  the  sternum  longitudinally  to  lessen  the 
symptoms  of  compression.  Should  a  benign  tumor  be  found,  it  might 
be  removed  successfully.  Friedrich  recommends  transverse  section 
of  the  sternum  above  the  third  rib.  Enlargement  of  the  thymus 
gland  is  referred  to  at  p.  741. 

SURGERY  OF  THE  LUNGS  AND  PLEURA. 

Subcutaneous  Injuries. — Subcutaneous  injuries  of  the  thoracic 
viscera  usually  are  accompanied  by  fractures  of  the  ribs  or  sternum; 
but  sometimes  the  lung  is  ruptured  without  there  being  any  coinci- 
dent injury  of  the  elastic  thoracic  cage.  In  most  cases  the  lung  is 
directly  crushed,  but  it  is  possible  for  it  to  be  injured  by  wrenching 
from  its  pedicle,  or  by  being  torn  loose  from  pleural  adhesions.  The 
extent  of  the  lesion  varies  from  mere  bruising  to  extensive  laceration, 
and  the  resulting  hemorrhage  may  be  slight  or  very  severe.  In  the 
mildest  cases  the  visceral  pleura  is  not  ruptured,  and  the  symptoms 
are  those  of  a  localized  pneumonia,  possibly  with  the  development 
of  subcutaneous  emphysema  commencing  at  the  root  of  the  neck 
(p.  776).  When  the  visceral  pleura  is  ruptured,  hemorrhage  occurs 
into  the  pleural  cavity,  and  the  air  also  usually  escapes  from  the 
lung,   forming   a   pneumo-hemothorax. 

Diagnosis. — The  diagnosis  depends  on  ascertaining  the  history  of  an 
injury;  on  the  symptoms,  which  do  not  differ  from  those  of  pene- 
trating wounds  of  the  lung  (see  below);  and  on  the  physical  signs 
of  pneumothorax  and  surgical  emphysema.  The  differential  diagnosis 
from  traumatic  diaphragmatic  hernia  may  be  difficult;  this  is  dis- 
cussed at  p.  802. 

Treatment. — The  treatment  consists  primarily  and  chiefly  in 
rest,  either  in  the  recumbent  or  sitting  posture,  whichever  is  more 
comfortable  to  the  patient.  The  administration  of  opium  in  some  form 
is  decidedly  beneficial,  allaying  the  annoying  cough,  slowing  the  respira- 
tion, and,  therefore,  diminishing  the  bleeding.  In  many  cases  the 
bleeding  stops  of  itself.  The  blood-pressure  in  the  pulmonary  system 
is  only  one-third  of  that  in  the  systemic.  If  bleeding  does  not  cease, 
as  indicated  by  persistent  symptoms  of  internal  hemorrhage,  and  by 
gradual  increase  in  the  amount  of  pleural  effusion,  it  must  be  checked 
by  operative  means,  as  described  below  in  connection  with  penetrating 
wounds  of  the  lung.  If  the  pneumothorax  persists  and  causes  dyspnea, 
the  air  may  be  aspirated ;  for  this  a  very  fine  needle  should  be  used,  as 
less  liable  to  cause  subcutaneous  emphysema.    The  surgeon  should  not 


PENETRATING  WOUNDS  OF  THE  THORAX 


783 


resort  to  this  measure  unnecessarily,  since  relief  of  the  pneumatic 
pressure  on  the  lung  may  cause  recurrence  of  bleeding. 

Prognosis. — The  prognosis  is  grave  except  in  the  case  of  trivial 
lesions.  Moller,  in  1910,  reported  23  cases  from  Korte's  clinique; 
no  operation  was  attempted  in  any  case,  and  none  would  have  been 
of  any  avail  in  the  9  fatal  cases. 


Fig.  839. — Cross-section  of  thorax  at  level  of  eighth  thoracic  vertebra.     Pleura 
cavities  outlined  in  black. 


Penetrating  Wounds  of  the  Thorax. — These  are  chiefly  gunshot 
or  stab  wounds.  The  former  have  been  considered  at  p.  209.  In 
most  cases  of  stab  wounds  the  lung  is  injured,  but  penetration  of 
the  parietal  pleura  without  visceral  injury  is  possible.  In  the  latter 
case  intrapleural  hemorrhage  (hemothorax)  may  occur  from  injury 
of  a  vessel  in  the  thoracic  wall;  and  there  usually  is  pneumothorax, 
air  being  sucked  into  the  pleural  cavity  at  each  inspiration.  Com- 
plicating injuries  of  the  diaphragm  and  abdominal  viscera  are  fre- 
quent. If  the  lung  has  been  wounded  there  may  be  considerable 
shock,  with  dyspnea,  cough,  and  usually  spitting  of  blood  (hemoptysis). 
In  many  cases  there  are  the  symptoms  of  severe  internal  hemorrhage 
(p.  259).  The  physical  signs  are  those  of  pneumothorax,  or  hemo- 
pneumothorax;  sometimes  there  is  hemorrhage  from  the  wound. 
Escape  of  air  from  the  wounded  lung  through  the  external  wound 
occasionally  occurs;  it  is  known  as  traumatopnea,  and  should  not 
be  confused  with  the  mere  aspiration  of  air  into  the  pleural  cavity 
such  as  was  described  as  occurring  even  when  no  pulmonary  injury 
is  present.  Prolapse  of  the  lung  through  the  wound  is  a  rare  occur- 
rence; this  should  not  be  confused  with  subcutaneous  hernia  of  the 
lung,  which  is  described  at  p.  786. 


784  SURGERY  OF  THE  LUNGS  AND  PLEURA 

Diagnosis. — Usually  this  is  not  difficult.  But  it  should  be  remem- 
bered that  alarming  intrapleural  hemorrhage  may  occur  from  injuries 
of  the  internal  mammary  and  intercostal  arteries,  without  wound  of 
the  lung;  and  the  possibility  and  extreme  seriousness  of  complicating 
stab  wounds  of  the  diaphragm  (p.  801)  should  be  kept  in  mind. 

Treatment. — The  constitutional  treatment  is  the  same  as  for  gun- 
shot wounds  or  subcutaneous  rupture  of  the  lung.  Under  no  cir- 
eunistances  should  the  wound  be  explored  with  finger  or  probe. 
The  surrounding  skin  should  be  painted  with  3  per  cent,  alcoholic 
solution  of  iodin,  the  wound  should  be  covered  immediately  with 
sterile  gauze,  and  the  side  of  the  chest  affected  should  be  firmly 
strapped  as  in  the  case  of  fractured  ribs.  This  materially  alleviates 
the  patient's  pain,  though  probably  it  has  little  influence  on  the 
progress  of  the  wound  in  the  lung. 

The  question  of  the  propriety  of  early  operative  interference  in  thoracic 
injuries  has  been  the  subject  of  much  discussion  during  the  last 
few  years;  and  some  surgeons  are  very  uncompromising  in  their 
attitude  for  or  against  intervention.  The  debate  is  waged  chiefly 
over  the  subject  of  stab  wounds,  the  propriety  of  non-interference 
in  the  case  of  bullet  wounds  in  civil  life,  except  for  positive  indications, 
being  very  generally  recognized.  In  the  case  of  subcutaneous  injuries, 
also,  a  decision  for  or  against  operation  is  not  very  difficult,  because 
the  symptoms  either  are  so  trivial  as  never  to  raise  the  question,  or 
the  lesions  are  so  manifestly  lethal  in  extent  as  to  render  operation 
useless.  But  in  the  case  of  stab  wounds  there  are  those  who  teach 
that  operation  is  never  or  hardly  ever  required;  and  there  are  others, 
equal  in  experience  and  authority,  who  maintain  that  evere  patient 
with  a  stab  wound  of  the  thorax,  seen  within  the  first  twelve  hours, 
should  be  taken  at  once  to  the  operating  room,  and  that  the  question 
of  operative  or  non-operative  treatment  should  be  decided  only 
after  an  exploratory  operation  has  been  done  to  determine  by 
inspection  the  extent  of  the  lesions.  Zeidler,  of  St.  Petersburg, 
with  an  immense  experience  in  this  class  of  cases,  takes  the  latter 
ground;  and  his  assistant  Lawrow  (1911)  has  exposed  his  views  very 
thoroughly.  Other  things  being  equal,  this  no  doubt  is  the  logical 
position  to  take;  but  the  fact  remains  that  if  it  is  adhered  to,  a  great 
many  unnecessary  operations  will  be  done;  and  in  many  cases  the 
patients  will  be  made  worse  or  will  be  killed  by  the  exploration. 

Most  surgeons  recognize  that  stab  wounds  which  might  involve 
the  diaphragm  or  abdominal  viscera  should  be  explored;  and  the 
fact  that  55  out  of  121  stab  wounds  of  the  thorax  (Lawrow)  came 
within  this  category  should  be  borne  in  mind.  It  is  recognized, 
moreover,  that  wounds  which  probably  injure  the  heart  should  be 
explored  (p.  268);  according  to  Lawrow's  figures  only  one  out  of 
ten  stab  wounds  of  the  thorax  implicates  the  heart.  But  when  these 
two  classes  of  stab  wounds  are  excluded,  there  certainly  remains  a 
large  number  of  cases  in  which  it  is  at  least  extremely  probable  that 
only  the  lung  has  been  injured,  or  that  even  though  the  pleura  has 


PENETRATING  WOUNDS  OF  THE  THORAX  785 

been  penetrated  there  is  no  visceral  injury  whatever;  and  it  is  interest- 
ing to  compare  the  results  secured  in  the  case  of  uncomplicated 
pulmonary  wounds  in  Zeidler's  service,  where  every  patient  who  con- 
sented was  subjected  to  early  operation,  with  those  reported  (1910)  by 
Moller  from  Korte's  clinique,  where  no  operations  were  done  in  such 
cases.  According  to  Zeidler's  immediate  exploration  plan  the  mor- 
tality in  52  uncomplicated  cases  was  27  per  cent.;  whereas  Korte 
treated  19  such  cases  without  one  death.  And  the  significance  of 
this  comparison  I  believe  is  not  altered  by  the  fact  that  in  78  per 
cent,  of  the  cases  explored  by  Zeidler  and  his  assistants  some  visceral 
injury  or  bleeding  from  an  intercostal  vessel  was  found. 

From  a  consideration  of  these  facts  I  think  it  is  evident  that  no 
hard  and  fast  rules  can  be  laid  down  for  treatment,  but  that  each 
individual  case  must  be  treated  on  its  own  merits.  In  fully  equipped 
hospitals,  I  believe  exploratory  operation  for  stab  wounds  of  the 
thorax  will  be  indicated  more  often  in  the  future  than  in  the  past; 
certainly  more  often  than  in  the  case  of  gunshot  wounds  or  crushes. 
But  I  cannot  believe  that  exploration  in  every  case  is  necessary  or 
desirable.  If  there  is  a  possibility  of  injury  of  the  heart,  or  of 
the  diaphragm  or  abdominal  viscera,  exploration  is  imperative;  but 
if  this  possibility  seems  remote,  it  is  better  to  treat  the  patient 
expectantly. 

As  indications  for  operation,  then,  may  be  recognized  the  following 
factors : 

1.  Possibility  of  injury  to  the  heart,  to  the  diaphragm,  or  abdominal 
viscera. 

2.  Active  hemorrhage  from  the  wound. 

3.  Signs  of  internal  hemorrhage,  recognized  by  constitutional 
symptoms,  and  by  steady  increase  in  the  amount  of  the  hemothorax. 
It  makes  no  difference  whether  this  comes  from  the  wounded  lung 
or  from  a  parietal  vessel.    The  bleeding  must  be  stopped. 

4.  Pneumothorax  which  develops  suddenly  some  days  after  the 
injury.  As  pointed  out  by  Moller  this  indicates  sloughing  or  reopening 
of  the  wound  in  the  lung;  and  immediate  drainage  of  the  pleura  is 
required  to  prevent  sepsis.  Primary  pneumothorax  scarcely  ever 
will  be  so  severe  as  to  demand  relief;  but  if  necessary  the  air  may 
be  aspirated  through  a  fine  needle.  If  this  fails,  the  only  relief  lies 
in  thoracotomy,  by  which  the  pressure  within  the  pleura  may  be 
reduced  to  that  of  one  atmosphere. 

Operation. — Usually  a  general  anesthetic  is  required.  Ether  is 
the  best,  and  if  possible  it  should  be  administered  by  intratracheal 
insufflation  (p.  154).  The  wound  is  carefully  explored,  cutting  down 
layer  by  layer,  until  it  is  ascertained  that  the  pleura  has  been  entered. 
Then  the  incision  is  extended  to  a  length  of  15  to  20  cm.  in  the 
wounded  interspace.  By  strong  retraction  of  the  ribs  (for  which  a 
rib-spreader  is  convenient)  it  may  be  possible  to  complete  the  operation 
without  resecting  any  of  the  ribs.  Resection  of  one  or  both  ribs 
bordering  on  the  primary  incision  may  be  done  later  if  necessary.  A 
50 


786  SURGERY  OF  THE  LUNGS  AND  PLEURA 

bleeding  intercostal  vessel,  which  may  be  the  only  source  of  hemor- 
rhage, should  be  looked  for  and  ligated.  The  pleura  having  been 
widely  opened,  the  thoracic  cavity  is  tamponed  by  hot  moist  gauze, 
and  the  diaphragm  is  inspected,  unless  there  is  good  reason  to  believe 
that  it  has  not  been  injured.  If  a  wound  is  found,  it  should  be  treated 
as  described  at  p.  801.  If  bleeding  continues,  the  lung  is  caught 
in  volsellum  forceps,  and  is  drawn  into  the  thoracic  incision.  This 
fixes  the  mediastinum,  promotes  cardiac  action,  and  ventilates  the 
other  lung.  The  lung  is  then  searched  for  wounds,  and  these  are 
sutured  with  mattress  sutures  of  fine  chromic  gut,  introduced  close 
to  the  border  of  the  wound,  passed  deeply,  but  not  drawn  very  tight. 
Round-pointed  needles  should  be  used.  A  wound  of  exit  as  well 
as  one  of  entrance  should  be  looked  for.  If  the  wounds  cannot  be 
sutured,  they  should  be  packed;  or  a  very  extensive  wound  may  be 
"exteriorized"  by  suturing  its  margins  to  the  edges  of  the  parietal 
wound.  After  the  pulmonary  wound  has  been  sutured  the  lung 
will  expand  if  intratracheal  insufflation  is  being  employed,  and  the 
blood  which  has  collected  in  the  pleural  cavity  will  be  forced  out  of 
the  thoracic  incision.  If  it  is  not,  the  pleura  should  be  wiped  dry. 
No  irrigation  should  be  employed.  The  parietal  wound  is  then  closed 
in  layers  (pleura,  intercostal  muscles,  and  skin),  without  drainage. 
If  the  anesthetic  has  been  administered  in  the  usual  way  it  will  be 
safer  to  leave  a  drainage  tube  in  the  incision  for  a  few  days;  this 
should  be  just  long  enough  to  enter  the  pleura.  In  22  cases  where 
the  wound  was  closed  without  drainage,  subsequent  drainage  for 
empyema  or  abscess  was  required  only  in  13  (Stuckey);  the  other 
9  patients  recovered  without  any  complication,  and  if  all  had  been 
drained,  all  would  have  had  empyema. 

Hernia  of  the  Lung  is  rare.  When  congenital  it  may  be  due  to 
defect  in  the  chest  wall,  or  may  develop  at  the  root  of  the  neck. 
Acquired  cases  usually  follow  some  months  or  years  after  injury  of 
the  thorax,  the  lung  bulging  out  beneath  the  cicatrix.  The  swelling 
is  sponge-like  in  consistency,  crepitates  on  pressure,  and  is  reducible; 
it  increases  in  size  during  forced  expiration,  may  disappear  spon- 
taneously during  inspiration,  and  gives  an  impulse  on  coughing. 

Treatment. — Treatment  seldom  is  required.  If  support  by  pads  or 
adhesive  plaster  does  not  secure  relief,  an  operation  may  be  under- 
taken, dissecting  out  the  cicatrix,  and  repairing  the  wound  by  over- 
lapping its  edges  in  several  layers.  The  pleural  cavity  need  not  be 
opened. 

Pneumothorax.  —  The  presence  of  air  in  the  pleural  cavity  as  a 
complication  of  injuries  of  the  thorax  has  been  alluded  to.  Occa- 
sionally the  condition  arises  from  disease  of  the  lung,  usually  tuber- 
culous; but  such  cases  have  little  surgical  importance.  The  pneumo- 
thorax may  be  open  or  closed:  that  is,  there  may  or  may  not  be  a 
wound  of  the  thoracic  parietes  producing  a  communication  between 
the  pleura  and  the  outer  atmosphere.  If  there  is  no  external  wound 
(when  the  pneumothorax  is  due  to  escape  of  air  from  the  wounded 


HEMOTHORAX  787 

or  diseased  lung),  or  if  the  thoracic  wound  is  small  or  valvular,  the 
pressure  of  the  air  in  the  pleura  may  be  increased  at  each  respiration, 
and  a  "tension  pneumothorax"  is  said  to  exist. 

Symptoms. — The  symptoms  depend  upon  the  rapidity  with  which 
the  pneumothorax  develops,  and  on  the  air  pressure.  A  very  suddenly 
produced  pneumothorax  may  cause  immediate  death  from  distortion 
of  the  mediastinum,  and  interference  with  the  action  of  the  heart  or 
the  other  lung.  One  of  very  slow  onset  may  produce  no  appreciable 
symptoms.  When  traumatic  in  origin,  the  symptoms  often  are 
obscured  by  those  of  shock,  internal  hemorrhage,  etc.  Unless  the 
lung  is  bound  down  by  adhesions,  the  air  fills  the  entire  pleural  cavity, 
and  the  entire  side  of  the  chest  affected  becomes  tympanitic  on 
percussion.  There  is  absence  of  respiratory  movements,  no  breath 
sounds  are  heard,  and  vocal  fremitus  is  absent.  If  the  air  is  under 
extremely  high  pressure  a  dull  note  may  be  obtained  on  percussion; 
this  is  rare.  Almost  always  there  is  dyspnea;  there  may  be  cyanosis; 
the  cardiac  action  may  be  embarrassed,  and  the  pulse  usually  is  weak, 
not  very  rapid,  and  may  be  irregular. 

Treatment. — In  most  cases  of  closed  pneumothorax  the  air  will  be 
absorbed  spontaneously  within  a  few  days,  and  no  treatment  is 
required.  If  dyspnea  is  severe  the  air  may  be  aspirated.  For  this 
a  very  fine  needle  should  be  used,  so  as  not  to  produce  subcutaneous 
emphysema.  In  cases  of  open  pneumothorax  relief  of  symptoms 
usually  follows  closure  of  the  external  wound  by  suture  or  occlusive 
dressing.  This  restores  the  piston  action  of  the  diaphragm,  ventilates 
the  other  lung,  and  facilitates  heart  action.  If  for  any  reason  the 
wound  cannot  be  closed,  and  the  symptoms  of  a  tension  pneumothorax 
supervene,  it  is  better  to  enlarge  the  parietal  wound  or  to  introduce 
a  drainage  tube,  thus  reducing  the  intrapleural  pressure  to  that  of 
one  atmosphere. 

Hemothorax. — Blood  in  the  pleural  cavity  almost  invariably  is 
the  result  of  injury  to  the  thorax,  either  subcutaneous  or  penetrat- 
ing. The  hemorrhage  may  be  derived  from  the  lung  or  from  the 
internal  mammary  or  one  of  the  intercostal  vessels.  Bleeding  from 
parietal  vessels  is  not  likely  to  stop  of  its  own  accord,  owing  to  the 
negative  pressure  within  the  pleural  cavity.  If  the  bleeding  comes 
from  the  lung  it  will  not  cease  until  the  intrapleural  pressure  equals 
the  blood-pressure  within  the  lung;  but  as  this  is  only  one-third  as 
great  as  that  in  the  systemic  circulation,  intrapleural  hemorrhage 
from  a  lung  wound  will  stop  of  itself  much  sooner  than  will  bleeding 
from  an  intercostal  artery. 

The  physical  signs  are  those  of  pleural  effusion.  The  symptoms  of 
internal  hemorrhage  indicate  the  nature  of  the  effusion,  and  this 
may  be  proved  by  aspiration.  The  blood  does  not  clot  very  readily, 
and  forms  an  excellent  culture  medium  for  bacteria.  Hence  there  is 
great  danger  of  secondary  empyema.  If  infection  does  not  occur, 
and  the  blood  finally  clots  and  becomes  organized,  extensive  and 
perhaps  disabling  pleural  adhesions  may  develop.     I  have  operated 


7SS  SURGERY  OF  THE  LUNGS  AND  PLEURA 

on  a  patient  with  calcification  of  the  entire  pleura,  the  result  of 
injury  many  years  previously. 

Treatment.— This  depends  upon  the  rapidity  of  the  hemorrhage  as 
well  as  upon  its  extent.  Rapid  bleeding  (indicated  by  the  symptoms 
of  internal  hemorrhage  and  by  rapid  increase  in  the  amount  of  fluid 
in  the  pleura)  usually  indicates  an  extensive  pulmonary  lesion,  and 
demands  operation,  as  described  under  stab  wounds  of  the  lung 
(p.  785).  If  the  bleeding  is  slower,  it  is  better  not  to  interfere  unless 
the  upper  level  of  the  dulness  (in  the  sitting  posture)  ascends  as  high 
as  the  spine  of  the  scapula,  or  unless  the  symptoms  of  hemorrhage 
are  very  pronounced. 

Pneumo-hemothorax. — Pneumo-hemothorax  is  more  frequent  than 
either  pneumothorax  or  hemothorax  separately.  The  air  rises  to  the 
upper  part  of  the  pleural  cavity,  and  the  blood  gradually  accumulates 
below.  The  physical  signs  are  those  of  pyo-pneumothorax,  which 
are  described  in  every  text-book  of  general  medicine.  The  diagnosis 
depends  on  a  recognition  of  these,  and  on  a  history  of  recent  injury 
and  on  the  symptoms  of  internal  hemorrhage.  Aspiration  of  the 
fluid  proves  its  hemorrhagic  nature.  Differentiation  from  diaphrag- 
matic hernia  (p.  802)  may  be  difficult.  Treatment  has  been  discussed 
sufficiently  under  the  separate  headings  pneumothorax  and  hemo- 
thorax. 

Chylothorax. — Chylothorax  usually  is  due  to  rupture  of  the  thoracic 
duct,  which  may  occur  as  a  complication  in  some  cases  of  fracture  of 
the  spine.  The  effusion  is  left-sided,  but  owing  to  more  serious  injuries 
often  is  overlooked.  Rapid  emaciation  is  characteristic,  but  the 
diagnosis  cannot  be  certain  until  some  of  the  fluid  has  been  withdrawn 
by  aspiration;  and  microscopical  and  perhaps  chemical  study  may  be 
necessary  then  to  determine  its  nature,  as  an  effusion  similar  in 
macroscopical  appearances  sometimes  occurs  in  cases  of  malignant 
disease  of  the  pleura.  Treatment  is  unsatisfactory.  In  some  cases 
repeated  aspiration  has  been  followed  by  recovery. 

Hydrothorax. — Hydrothorax  is  the  term  used  to  describe  a  collec- 
tion of  non-inflammatory  fluid  (transudate)  in  the  pleural  cavity.  It 
presents  little  surgical  interest. 

Pleurisy  or  Pleuritis  is  an  inflammation  of  the  pleura,  almost 
invariably  of  bacterial  origin,  and  in  the  vast  majority  of  cases  due  to 
infection  transmitted  from  the  lung.  It  may  result  from  hematogen- 
ous infection,  but  this  is  rare.  It  is  always  present  in  some  degree 
in  cases  of  penetrating  wounds  of  the  thorax.  In  the  early  stages  of 
the  inflammation  a  plastic  exudate  is  formed,  and  if  the  process  stops 
here,  recovery  with  more  or  less  extensive  pleural  adhesions  may 
occur.  Such  cases  form  about  one-fifth  of  the  total  cases  of  pleurisy 
(Fraley,  1907)  and  seldom  come  under  surgical  care.  In  about  three- 
fifths  of  cases  serous  effusion  occurs,  and  in  about  one-fifth  more  this 
effusion  finally  becomes  purulent  (pyo-thorax) .  If  adhesions  have 
formed  early,  or  in  a  previous  attack  of  pleurisy,  the  effusion  may  be 
encapsulated;  its  site  then  may  be  between  the  lung  and  the  parietal 


PYOTHORAX,  OR  EMPYEMA   THORACIS  789 

pleura,  between  two  lobes  of  the  lung,  or  between  the  lung  and  dia- 
phragm. In  cases  where  there  are  no  adhesions  the  fluid  lies  free  in 
the  pleural  cavity  and  forces  the  lung  upward  and  backward  into  the 
spinal  gutter.  The  symptoms  of  pleurisy  with  effusion  are  detailed 
in  every  text-book  on  general  medicine,  and  need  not  be  recounted 
here.  The  diagnosis  is  confirmed  by  exploratory  puncture  with  an 
aspirating  syringe. 

Treatment. — If  the  effusion  is  large  and  if  no  tendency  to  reabsorp- 
tion  is  manifested,  and  particularly  if  the  constitutional  symptoms 
indicate  suppuration,  the  fluid  should  be  aspirated,  as  described  at 
p.  149.  The  needle  is  passed  close  to  the  upper  border  of  the  rib, 
in  the  sixth,  seventh,  or  eighth  interspace,  usually  in  the  posterior 
axillary  line  or  below  the  angle  of  the  scapula.  The  site  may  be 
anesthetized  by  a  hypodermic  injection  of  novocain  or  by  ethyl  chloride 
spray.  Seldom  is  it  necessary  to  withdraw  all  the  fluid,  as  the  relief 
of  tension  secured  by  aspiration  of  a  portion  may  hasten  absorption 
of  the  remainder. 

Pyothorax,  or  Empyema  Thoracis,  is  a  collection  of  pus  within 
the  pleural  cavity.  Usually  it  results  from  rupture  of  a  small  sub- 
pleural  pulmonary  abscess  (Moschcowitz,  1919).  It  is  the  suppurative 
stage  of  pleurisy  with  effusion;  but  in  many  cases  suppuration  occurs 
so  rapidly  that  no  anterior  stage  of  serous  effusion  can  be  recognized. 
In  no  case  is  there  any  sharp  line  of  distinction  to  be  drawn  between 
the  two  conditions,  as  the  serous  exudate  (when  one  exists)  gradually 
becomes  sero-purulent,  and  this  in  turn  assumes  the  usual  character  of 
pus;  but  in  every  case  before  true  pus  is  formed,  adhesions  set  certain 
limits,  large  or  circumscribed,  to  the  cavity  in  which  the  pus  is  found. 
The  pus  may  sink  to  the  bottom  of  the  cavity  as  a  heavy  flocculent 
sediment,  and  the  supernatant  liquid  may  remain  comparatively  clear. 

Pyothorax  is  most  frequent  in  children,  especially  as  a  complication 
or  result  of  a  lobar  pneumonia,  the  infecting  organism  being  the 
pneumococcus.  Pneumonia  is  followed  by  empyema  in  from  5  to  10 
per  cent,  of  cases.  In  adults  men  are  affected  much  oftener  than 
women,  and  the  empyema  results  less  often  from  a  frank  pneumonia; 
in  many  cases  the  staphylococcus  or  streptococcus  is  the  infecting 
organism,  and  these  may  appear  as  secondary  infections  in  cases 
originally  caused  by  the  pneumococcus,  which  is  a  short-lived  organism. 

Unless  the  pus  is  evacuated  early,  the  parietal  and  visceral  pleura? 
become  thickened,  and  a  fixed  cavity  is  produced,  which  will  hinder 
expansion  of  the  lung  even  when  the  contained  fluid  has  been  removed. 
Adhesions  always  occur,  within  the  pleura,  and  the  empyema  whether 
small  or  large  is  encapsulated  either  on  the  surface  of  the  lung  (Fig.  846), 
between  its  lobes  (Fig.  840),  or  between  the  lung  and  diaphragm.  In 
rare  cases  the  pus  may  evacuate  itself  through  one  of  the  bronchial 
tubes  (pleural  vomica),  or  may  perforate  the  diaphragm  and  form  a 
subphrenic  abscess.  In  children  it  is  not  unusual  for  a  neglected 
empyema  to  break  through  an  intercostal  space  and  to  point  sub- 
cutaneously.      In  adults  this  is  rare  (Fig.  841).    This  condition  is 


790 


SURGERY  OF  THE  LUNGS  AND  PLEURA 


described  as  an  empyema  necessitatis.  If  the  empyema  ruptures 
externally,  which  is  very  unusual,  a  pleural  fistula  is  left,  and  this 
scarcely  ever  heals  spontaneously. 

Symptoms  ond  Diagnosis.  -Usually  the  empyema  is  secondary  to 
some  thoracic  condition  (pneumonia,  bronchitis,  injury)  for  which 
the  patient  has  been  under  treatment.  ///  children,  in  whom  the 
condition  is  most  frequent,  an  empyema  very  frequently  is  mis- 
taken for  an  unresolved  pneumonia;  but  this  condition  is  rare  in 
children,  and  if  an  aspirating  syringe  is  used,  as  it  should  be,  for 


rwg) 


Fig.  840. — Interlobar  empyema  ruptured  into  a  bronchus  (pleural  vomica). 
pleural  effusion  in  costo-phrenic  sinus.     Episcopal  Hospital. 


Note 


exploration  in  such  cases,  the  diagnosis  will  be  quickly  cleared  up. 
The  physical  signs  in  children  may  be  very  misleading,  as  the  breath 
sounds  may  be  quite  clearly  heard;  this,  with  the  persisting  dulness 
on  percussion,  causes  the  resemblance  to  unresolved  pneumonia. 
There  may  be  Skodaic  resonance  above  the  dull  area.  But  tactile 
fremitus  is  decreased,  and  the  mere  fact  of  a  lingering  pneumonia 
in  a  child  should  make  one  suspect  an  empyema.  Nor  should  failure 
to  draw  pus  at  the  first  puncture  make  the  physician  conclude  that 
it  is  absent,  if  the  constitutional  signs  of  sepsis  persist.  The  pus 
may  be  too  thick  to  run  through  the  needle  employed,  or  may  not  have 


PYOTHORAX,  OR  EMPYEMA   THORACIS 


791 


been  reached  by  the  needle.  In  advanced  cases,  however,  the  diagnosis 
is  easy ;  the  temperature  continues  elevated,  and  though  remissions  may 
occur  daily  or  oftener,  the  normal  is  not  reached.  The  apex  beat  of 
the  heart  may  be  displaced  by  large  effusions;  the  interspaces  of  the 
affected  side  may  bulge;  dilated  veins  may  cover  this  side  of  the  thorax; 
and  it  may  seem  larger  than  the  healthy  side,  though  its  respiratory 
excursions  are  less  than  normal  or  absent  (Fig.  842).  The  diagnosis 
from  subphrenic  abscess  is  considered  at  p.  865.  In  adults  the  diagnosis 
of  pleural  effusion  does  not  present  the  same  difficulties,  but  the  pres- 
ence of  pus  rarely  can  be  asserted  positively  unless  paracentesis  is  done. 


Fig.  841.  —  Empyema  necessitatis 
pointing  beneath  left  pectoral  muscles. 
Age  thirty-two  years;  phthisis  for  two 
years;  pneumonia  seven  months  ago. 
"Abscess  in  thorax"  for  five  weeks. 
(Dr.  Harte's  case.)  Pennsylvania 
Hospital. 


Fig.  842. — Pyothorax  on  the  left,  following 
pneumonia.  Age  seven  years;  duration  two 
weeks.  Note  x  on  apex  beat,  displaced  to 
right;  dyspneic  expression;  bulging  of  left 
intercostal  spaces,  and  well  marked  intercostal 
depressions  on  right.     Children's  Hospital. 


Treatment. — A  child  almost  in  articulo  mortis  may  be  saved  by 
prompt  evacuation  of  the  pus,  but  the  evacuation  should  not  be 
too  rapid  in  any  case  where  there  is  marked  dyspnea,  cyanosis,  etc., 
as  abrupt  change  in  the  intrapleural  pressure  may  cause  sudden 
death.  In  any  case  of  massive  effusion  (one  extending  as  high  as  the 
spine  of  the  scapula)  it  is  well  to  withdraw  half  or  three-fourths  of 
the  fluid  by  aspiration  before  proceeding  to  drain  the  chest. 

In  very  early  cases  of  seropurulent  effusion,  and  in  many  cases  of 
tuberculous  pyothorax,  it  may  suffice  to  aspirate  the  fluid,  and  at  once 
inject  50  to  100  c.c.  of  formalin-glycerin  solution  (2  per  cent.),  as  advised 
by  John  B.  Murphy.    A  week  later  the  fluid  is  aspirated  again,  being 


792  SURGERY  OF  THE  LUNGS  AND  PLEURA 

found  in  favorable  cases  less  purulent  and  more  serous;  another  injec- 
tion of  the  formalin-glycerin  solution  is  given,  and  at  the  third  or 
fourth  aspiration,  when  pure  serum  is  found,  the  fluid  is  allowed  to 
remain  in  the  pleura,  and  is  very  gradually  (months)  absorbed,  as  the 
lung  expands  and  the  chest  wall  sinks  in  until  the  cavity  is  obliterated. 

In  most  cases  of  pyothorax,  however,  thoracotomy  and  drainage  of 
the  abscess  is  the  best  treatment. 

Thoracotomy  or  Pleurotomy. — This  is  the  operation  of  opening  the 
thoracic  cavity  for  the  purpose  of  draining  an  empyema;  a  portion 
of  a  rib  is  excised  to  ensure  free  drainage  (Konig,  1878).  The  rib 
selected  depends  on  the  location  of  the  pus,  if  this  is  encapsulated; 
if  the  empyema  is  massive,  the  ninth  or  tenth  rib  below  the  angle  of  the 
scapula  is  the  best  site  for  drainage  (Fig.  844).  If  the  cavity  extends 
lower  than  the  rib  first  resected,  a  counterincision  (resecting  another 
rib)  should  be  made  at  the  lowest  level  for  dependent  drainage  (J. 
Ashhurst,  Jr.,  1894).  T.  T.  Thomas  (1913)  advocates  resection  of  the 
eleventh  rib  close  to  its  angle.  In  children  some  surgeons  prefer  an 
intercostal  incision,  without  resection  of  a  rib,  but  I  believe  even  in 
these  cases  convalescence  is  more  rapid  if  a  larger  opening  is  made. 

Dyspnea  should  be  relieved  by  aspirating  most  of  the  pus  before 
beginning  the  operation.  The  patient  is  not  to  be  turned  over  on  the 
healthy  side,  as  this  may  cause  arrest  of  respiration  or  cardiac  action. 
By  bringing  the  body  well  over  the  side  of  the  table  the  operation  may 
be  done  without  much  difficulty,  as  the  patient  lies  supine.  But  it  is 
much  more  convenient  to  have  the  patient  lie  prone;  respiration  is 
perfectly  easy  in  this  position  and  the  operative  pneumothorax  causes 
less  pulmonary  collapse  than  in  the  usual  position. 

The  operation  usually  may  be  done  under  local  anesthesia  (p.  157) : 
after  anesthetizing  the  skin  and  subcutaneous  tissues  as  usual,  the 
needle  is  inserted  in  the  intercostal  space  at  the  dorsal  extremity  of 
the  proposed  incision,  and  is  pushed  in  until  it  strikes  the  rib  next 
above  that  to  be  resected ;  its  point  is  then  manipulated  until  the  lower 
border  of  the  rib  is  found,  whereupon  it  passes  through  the  elastic 
resistance  offered  by  the  external  intercostal  muscle;  it  is  then  pushed 
still  a  little  further  in,  and  about  2  c.c.  of  a  0.25  per  cent,  solution  of 
novocain  are  injected  around  the  intercostal  nerve.  This  procedure 
is  repeated  in  the  interspace  next  below;  and  after  a  few  minutes  the 
intervening  rib  may  be  painlessly  resected.  In  some  cases,  especially 
in  children,  a  general  anesthetic  (ether)  is  to  be  preferred,  though  I  have 
employed  local  anesthesia  with  satisfaction  at  the  age  of  sixteen  months. 

An  incision  of  about  8  to  10  cm.  is  made  along  the  rib  selected, 
and  the  knife  is  carried  directly  down  to  the  bone.  Bleeding-points 
are  clamped.  The  periosteum  is  incised  and  is  stripped  from  the 
outer  surface  of  the  rib  throughout  the  length  of  the  incision,  by  means 
of  a  periosteal  elevator.  On  the  upper  surface  of  the  rib  strip  the 
periosteum  from  behind  forward,  and  on  the  inferior  surface  strip 
it  from  before  backward.  Then  the  periosteum  is  also  stripped  from 
the  deep  (pleural)  surface  of  the  rib,  keeping  the  instrument  close 


PYOTHORAX,  OR  EMPYEMA   THORACIS 


793 


Fig.  843. — Excision  of  a  rib  for  empyema. 


to  the  bone.  By  this  means  the  intercostal  vessels,  which  are  separated 
from  the  rib  by  its  periosteum,  are  pushed  aside  with  the  soft  parts. 
When  the  rib  has  been  thus  denuded  throughout  its  entire  circumfer- 
ence for  a  distance  of  about  5  cm.,  a  bone-cutting  forceps  or  a  special 
costotome  is  used  to  divide  the  rib  at  one  end  of  the  incision.  The 
portion  of  rib  to  be  excised  is  then  grasped  in  forceps,  and  the  rib  is 
divided  at  the  other  end  of  the  incision  (Fig.  843),  and  the  intervening 
portion  is  removed.  This  should  be  at  least  3  cm.  long.  The  parietal 
pleura,  still  covered  by  the  deep  layer  of  the  periosteum,  then  presents 
in  the  wound;  these  structures 
should  be  divided  in  the  axis  of 
the  rib  for  an  inch  or  more. 
In  some  cases  of  long  standing 
empyema  the  parietal  pleura 
may  be  very  thick.  There  is 
little  danger  of  wounding  the 
lung,  but  it  is  well  to  take  the 
same  precautions  as  in  opening 
the  peritoneum  (p.  873).  The 
intercostal     vessels     often    are 

thrombosed,  and  may  not  bleed  if  wounded;  if  the  periosteum  has  been 
stripped  carefully  from  the  rib  before  this  is  excised,  and  if  the  deep 
incision  is  made  nearer  the  upper  than  the  lower  border  of  the  rib, 
these  vessels  will  not  be  wounded.  If  they  are  wounded,  bleeding  from 
them  is  controlled  more  easily  by  a  mass  suture  than  by  a  ligature. 

As  soon  as  the  pleura  is  opened  a  general  anesthetic  if  used  should 
be  stopped.  The  pus  should  be  allowed  to  escape  slowly.  Violent 
paroxysms  of  coughing  may  occur.  The  surgeon  should  introduce  his 
ringer  from  time  to  time,  to  assist  the  discharge  of  masses  of  lymph. 
If  the  empyema  is  of  long  duration,  it  is  well  to  break  up  adhesions 
between  the  lung  and  chest  wall,  so  as  to  facilitate  its  subsequent 
expansion.  In  such  old  cases  the  infection  is  not  very  virulent,  and 
septic  absorption  is  not  to  be  feared.  In  acute  cases,  where  the  infec- 
tion is  more  active,  the  lung  is  not  firmly  bound  down,  and  its  release, 
therefore,  is  not  necessary. 

A  large  rubber  tube  (at  least  1.5  cm.  in  diameter)  is  then  passed 
5  to  10  cm.  within  the  parietal  pleura,  and  is  fixed  by  a  stitch  to  the  margin 
of  the  skin  wound.  If  not  thus  fixed  it  may  fall  into  the  pleural  cavity 
or  be  pulled  out  of  the  wound  accidentally.  An  extremely  abundant 
dressing  of  gauze  and  absorbent  cotton  is  applied,  and  the  patient  is 
returned  to  bed. 

After-treatment. — The  dressing  may  require  changing  several  times 
daily  at  first.  Masses  of  lymph  blocking  the  tube  should  be  removed 
with  forceps.  No  irrigation  of  the  cavity  should  be  employed.  In 
some  instances  this  has  caused  death.  As  soon  as  agreeable  the 
patient  should  be  propped  up  in  bed,  and  measures  must  be  adopted 
to  promote  expansion  of  the  lung.  Every  time  the  clock  strikes 
the  hour  the  patient  should  be  instructed  to  take  a  half  dozen  or  more 


794 


SURGERY  OF  THE  LUNGS  AND  PLEURA 


deep  respirations,  and  several  times  daily  he  should  blow  water  from 
one  Wonlff's  bottle  to  another  (Fig.  845).    Children  may  exercise  their 


46YRS 


a  dys 


8    DYS. 


Fig.  844. — Three  patients  with  empyema.  The  upper  figures  indicate  the  ages,  the 
lower  figuies  the  intervals  since  operation.  Uneventful  recovery  in  all.  Episcopal 
Hospital. 


Fig.  845. — Blowing  through  Woulff's  bottles  to  expand  lung  after  thoracotomy 
for  empyema.     Episcopal  Hospital. 

lungs  by  blowing  up  toy  balloons,  sounding  trumpets,  etc.    Patients 
should  be  got  out  of  bed  as  soon  as  possible. 


ENCAPSULATED  EMPYEMA 


795 


Convalescence  often  is  tedious,  and  may  be  interrupted  by  pneu- 
monic or  pleuritic  attacks,  with  evidences  of  septic  absorption. 
This  usually  is  due  to  interference  with  drainage  of  the  wound. 
In  favorable  cases  the  tube  does  not  require  to  be  replaced  when 
once  removed  at  the  expiration  of  ten  days  or  two  weeks.  As  judged 
by  the  results  of  operation,  the  mortality  from  empyema  is  about 
20  to  25  per  cent.;  but  as  practically  all  patients  die  unless  operated 
on,  and  as  the  death  rate  from  the  primary  pneumonia  is  very  high, 
the  operation  must  be  regarded  as  a  distinct  life-saving  measure. 


Fig.  846. — Large  but  distinctly  encapsulated  empyema.     Episcopal  Hospital. 

Encapsulated  Empyema. — The  situation  of  the  interlobar  fissures 
should  be  re-collected  (Fig.  846),  as  they  are  frequently  the  starting- 
place  of  an  empyema.  If  the  symptoms  and  physical  signs  indicate  the 
presence  of  pus  within  the  chest,  I  believe  exploratory  thoracotomy  is 
justified,  even  if  pus  cannot  be  located  by  repeated  puncture.  The 
operation,  done  under  local  anesthesia,  consists  in  resecting  8  to  10  cm. 
of  the  eighth  and  ninth  ribs  below  the  angle  of  the  scapula,  in  walling 
off  the  healthy  pleural  cavity  with  hot  moist  gauze,  and  in  searching 
between  lung  and  diaphragm,  between  lung  and  chest  wall,  and  between 


79G 


SURGERY  OF  THE  LUNGS  AND  PLEURA 


the  lobes  of  the  lung,  for  the  abscess.  This  is  then  drained  by  tube, 
across  the  pleural  cavity.  I  reported  a  series  of  such  operations  in 
1916. 

Bilateral  Empyema. — Bilateral  empyema  is  most  frequent  in 
children.  Fabrikant  (1911)  collected  118  cases,  with  a  mortality  of 
37  per  cent.  The  second  side  should  be  operated  on  a  few  days  after 
the  first. 

Pleural  Fistula.  Pleural  fistula  may  persist  for  years  after  the  evac- 
uation of  an  empyema,  unless  properly  treated,  and  may  lead  to  death 
from  exhaustion,  amyloid  degeneration  of  the  viscera,  secondary 
tuberculosis,  or  some  intercurrent  disease.  If  the  empyema  has  been 
recognized  early,  and  has  been  evacuated  promptly  by  a  large  incision 
low  enough  to  secure  efficient  drainage,  the  resulting  sinus  closes  in  a 

month  or  two.  Sometimes  the 
thoracic  wound  closes  on  a  persist- 
ing pneumothorax;  but  if  the  latter 
is  sterile  or  nearly  so,  the  sinus  may 
not  have  to  be  reopened,  the  lung 
gradually  expanding  against  the 
chest  wall.  It  is  in  cases  of  chronic 
empyema,  where  the  lung  is  bound 
down  by  dense  adhesions,  that  a 
large  thoracic  cavity  remains.  From 
such  an  incompletely  drained  cavity 
half  a  liter  or  more  of  pus  may  be 
discharged  daily;  and  when  sapro- 
phytic infection  is  added,  the  dis- 
charge is  exceedingly  putrid,  and  the 
patient  is  loathsome  to  himself  and 
to  all  around  him.  The  thorax  be- 
comes deformed,  curvature  of  the 
spine  develops  (Fig.  847),  and  the 
patient  is  a  helpless  cripple.  Club- 
bing of  the  ringers  is  frequent 
(Fig.  557),  and  other  joint  changes 
may  add  to  his  misery  (pulmonary 
osteoarthropathy,  p.  518. 
Treatment. — Treatment  depends  upon  the  extent  and  duration  of 
the  sinus.  A  small  and  recent  sinus,  which  does  not  discharge  very 
much  pus,  often  may  be  made  to  heal  by  bismuth  paste  injections 
(Ochsner,  1909),  as  used  for  tuberculous  sinuses  (p.  527).  This 
method,  with  skiagraphy,  is  valuable  in  determining  the  size  of  the 
cavity  within  the  thorax. 

If  drainage  is  not  free,  the  sinus  should  be  enlarged,  under  an 
anesthetic,  and  the  surgeon  should  break  up  with  his  finger  the 
adhesions  between  the  lung  and  parietal  pleura;  and  if  the  cavity 
is  large,  he  should  resect  another  rib  at  its  most  dependent  portion, 
and  drain  from  the  lower  opening. 


Fig.  847. — Scoliosis,  nine  months 
after  operation  for  empyema;  fistula 
still  discharges  250  c.c.  of  pus  daily. 
Episcopal  Hospital. 


PLEURAL  FISTULA  797 

Sometimes  the  sinus  is  kept  from  healing  by  the  presence  of  a 
drainage  tube  which  has  been  lost  inside  the  wound.  This  may  be 
detected  by  a  skiagraph. 

Information  derived  from  use  of  the  a>ray  may  be  an  aid  in  the 
prognosis:  if  the  collapsed  lung  is  permeable  to  air  the  a>ray  will 
show  decreased  density  during  forced  expiration;  and  if  the  lung 
shows  a  tendency  to  expand  during  coughing,  it  is  probable  no  further 
operation  will  be  required  (Destot  and  Violet,  1904).  For  cases 
in  which  the  lung  is  permeable,  but  where  no  tendency  to  expansion 
is  apparent,  Carrel-Dakin  treatment,  or  decortication  or  discission,  as 
described  below,  should  be  adopted.  If  the  lung  neither  shows  a  ten- 
dency to  expand  nor  is  permeable  to  air,  the  only  way  to  efface  the 
pleural  cavity  is  to  resect  the  bony  thoracic  cage  overlying  it,  and  thus 
to  allow  the  soft  parts  to  fall  in  against  the  lung  (Estlander,  Schede). 
Carrel-Dakin  Treatment.— -If  treatment  as  above  indicated  fails  to 
bring  about  closure  of  the  sinus,  resort  may  be  had  to  systematic  use 
of  the  Carrel-Dakin  technique  (p.  170)  for  the  chemical  sterilization  of 
the  cavity.  The  hypochlorite  solution  thus  employed  will  gradually 
destroy  the  exudate  covering  the  visceral  pleura,  permitting  progressive 
expansion  of  the  lung;  and  when  repeated  cultures  (not  merely  smears) 
indicate  that  sterility  has  been  attained,  the  Carrel  tubes  may  be 
entirely  withdrawn,  an  occlusive  dressing  applied  over  the  sinus,  and 
this  may  be  allowed  to  close  upon  the  remaining  pneumothorax,  which 
in  some  cases  will  eventually  be  obliterated  by  the  mutual  approach  of 
lung  and  chest  wall.     In  many  the  sinus  will  re-open. 

Decortication  of  the  Lung  (Fowler,  Delorme,  1893). — This  consists 
in  opening  the  old  cavity  of  the  empyema,  obtaining  sufficient  exposure 
to  enable  the  surgeon  to  explore  the  entire  interior  of  the  empyema 
cavity.  Lilienthal  (1919)  employs  division  of  the  ribs  between  scapula 
and  spinal  column,  combined  with  an  intercostal  incision  in  the  seventh 
or  eighth  space.  The  most  important  step  is  to  free  the  lung  thoroughly 
from  its  attachments  to  the  parietal  pleura.  This  is  best  done  by  mak- 
ing an  incision  through  the  latter  close  to  the  outer  or  posterior  margin 
of  the  lung  along  the  spinal  gutter.  The  fingers  are  then  inserted 
between  the  posterior  thoracic  wall  and  the  lung,  and  the  latter  is 
gradually  freed.  Its  natural  elasticity  and  tendency  to  expansion  aid 
in  this  manoeuvre.  When  the  lung  is  thus  freed  posteriorly  it  may  be 
possible  to  peel  the  remains  of  the  abscess  wall  off  its  surface.  The 
thoracic  wound  is  then  closed  with  drainage,  and  the  case  is  treated  as 
one  of  recent  empyema.  The  results  are  very  satisfactory,  the  lung 
expanding  and  the  abscess  cavity  becoming  obliterated. 

Discission  of  the  Pleura  (Ransohoff,  1903)  is  adopted  in  cases  where 
decortication  proves  difficult  or  impossible.  If  the  dense  membrane 
overlying  and  compressing  the  lung  is  scored  by  the  knife,  down  to 
the  lung  tissue  proper,  the  incision  will  gape  widely;  and  if  a  number 
of  such  incisions  are  made  in  parallel  and  criss-cross  lines,  each  inci- 
sion will  gape  so  widely  that  the  lung  will  expand  to  a  very  surprising 
degree. 


798  SURGERY  OF  THE  LUNGS  AND  PLEURA 

Thoracoplasty,  Estlander's  Operation  (1877).— This  consists  in  the 
resection  of  several  ribs  (three  to  five),  for  a  considerable  extent, 
directly  over  the  old  empyema  cavity,  in  order  to  allow  the  soft 
parts  of  the  thoracic  wall  to  fall  in  against  the  collapsed  and  non- 
expansile  lung.  The  cavity  is  thus  wholly  or  in  part  obliterated.  In 
very  large  cavities  the  operation  may  not  effect  a  cure,  but  the  result 
is  "the  difference  between  having  a  large  abscess  discharging  a  great 
quantity  of  pus,  and  a  small  sinus  which  weeps  a  little  thin  fluid." 
(J.  Ashhurst,  Jr.,  1894.)  The  operation  may  well  be  combined  with 
free  separation  of  the  lung  from  its  parietal  adhesions,  especially 
posteriorly — a  modified  form  of  decortication.  Schede's  Operation 
(1890)  consists  in  resection  of  nearly  the  entire  bony  wall  of  the  side 
of  the  thorax  affected.  This  is  exposed  by  reflecting  an  immense  flap 
extending  from  the  second  costal  cartilage  anteriorly,  to  the  costal 
margin  below,  and  to  the  spine  of  the  scapula  posteriorly.  After 
removal  of  the  ribs,  this  flap  is  applied  against  the  exposed  lung. 
This  operation  has  a  high  mortality  and  is  rarely  done  at  the  present 
day,  when  earlier  and  more  thorough  treatment  of  the  acute  empyema 
enables  the  patients  to  recover  without  such  immense  cavities.  In 
no  cases  should  it  be  attempted  until  decortication  and  Estlander's 
operation  have  failed. 

Tuberculosis  of  the  Pleura,  usually  secondary  to  that  of  the  lung 
or  bronchial  lymph  nodes,  presents  little  surgical  interest  except 
in  cases  with  effusion.  Most  painless,  slowly  developed,  and  appar- 
ently causeless  cases  of  pleural  effusion  in  adults  are  tuberculous. 
The  condition  is  recognized  by  the  physical  signs  of  pleural  effusion, 
and  the  nature  of  the  fluid  may  be  suspected  from  the  patient's 
history.  Diagnostic  puncture  reveals  straw-colored  or  slightly 
turbid  fluid,  rarely  blood-tinged.  Tubercle  bacilli  seldom  can  be 
discovered,  but  a  high  lymphocyte  count  may  suggest  the  tuberculous 
nature  of  the  fluid,  and  inoculation  experiments  usually  will  confirm 
the  diagnosis.  The  condition  is  to  be  regarded  as  one  of  cold  abscess. 
Secondary  infection,  from  the  perforation  of  a  tuberculous  cavity 
in  the  lung  into  the  pleura,  is  not  very  uncommon,  forming  a  pyo- 
pneumothorax. Secondary  infection  may  also  occur  through  the 
blood  or  from  the  unruptured  lung. 

Treatment. — Local  treatment  is  entirely  secondary  in  importance 
to  the  general  treatment  of  the  tuberculous  patient.  Only  if  the 
effusion  is  massive,  and  causes  dyspnea,  should  any  of  the  fluid  be 
withdrawn  by  aspiration.  If  much  fluid  is  withdrawn  damage  may 
be  done  to  the  diseased  lung,  or  a  recently  closed  communication 
with  the  lung  may  be  reopened.  After  some  of  the  fluid  is  withdrawn 
the  remainder  may  be  gradually  absorbed.  If  on  aspiration  the  fluid 
is  found  to  be  verging  on  suppuration  (from  secondary  infection), 
50  c.c.  of  formalin-glycerin  solution  (2  per  cent.),  should  be  injected. 
Under  no  circumstances  should  the  pleura  be  opened  by  incision,  or 
drainage  be  established:  such  a  course  surely  invites  secondary  infec- 
tion, with  an  external  pyo-pneumothorax,  and  death  usually  occurs  in 


ABSCESS  AND  GANGRENE  OF  THE  LUNG  799 

a  few  weeks.  Secondary  tuberculosis  in  an  open  empyema  cavity  may 
occur,  but  is  not  so  quickly  fatal  as  a  primary  tuberculous  pleurisy 
secondarily  infected.  It  should  be  treated  as  other  cases  of  open 
pneumothorax  following  empyema,  with  special  attention  to  the 
patient's  general  health. 

Tuberculosis  of  the  Lungs. — Surgery  of  this  condition  may  be  said 
to  be  still  in  an  experimental  stage,  and  has  been  applied  mostly  to 
advanced  stages  of  the  disease  otherwise  incurable. 

In  1898  Murphy  introduced  to  surgical  notice  in  this  country  a 
plan  of  treatment,  previously  advocated  (1882)  by  Forlanini,  con- 
sisting in  injections  of  nitrogen  gas  into  the  pleural  cavity,  to  cause 
collapse  of  the  lung  and  thus  to  induce  rest  and  promote  healing  of  the 
pulmonary  lesions.  Nitrogen  is  said  to  be  more  slowly  absorbed 
than  any  other  gaseous  substance.  The  subject  has  been  exten- 
sively studied  by  Morelli  (1918).  Pneumonotomy,  to  drain  cavities 
in  the  lung,  has  been  done  on  numerous  occasions;  the  first  formal 
operation  is  the  historic  one  of  Baglivi  in  1643.  It  is  conceivable 
that  with  the  present  improvements  in  the  technique  of  pulmonary 
surgery  such  operation  may  find  a  legitimate  field  in  the  future  for 
the  rare  cases  in  which  an  apical  cavity  is  not  draining  well,  and  in 
which  no  other  discoverable  tuberculous  lesions  exist.  Partial  pneu- 
monectomy was  done  by  Tuffier  in  1891;  he  removed  the  apex  of  one 
lung,  containing  an  early  focus  of  tuberculosis.  The  patient  recovered 
and  was  in  good  health  four  years  later.  Medical  and  hygienic  treat- 
ment will  cure  such  patients,  and  no  operation  should  be  done.  Est- 
lander's  Operation  was  suggested  in  1891  by  O.  H.  Allis  as  a  means 
by  which  collapse  of  a  pulmonary  cavity  might  be  secured,  with 
improved  chance  of  its  healing;  and  this  operation  has  been  employed 
by  Quincke  and  others.  Friedrich  (1909)  has  employed  Schedcs 
method  for  the  purpose  of  causing  collapse  of  a  tuberculous  lung, 
the  other  lung  being  healthy,  or  exhibiting  no  evidence  of  active 
disease.  W.  Meyer  (1920)  refers  to  150  such  operations  in  patients 
with  pulmonary  tuberculosis.  Freeman  (1909)  resected  the  upper  ribs, 
and  after  the  wound  had  healed  adjusted  a  hernial  truss  over  the  apex 
of  the  lung  to  cause  obliteration  of  a  tuberculous  cavity.  Freund's 
operation  of  chondrectomy,  as  in  cases  of  pulmonary  emphysema,  has 
also  been  employed  in  cases  of  pulmonary  tuberculosis,  to  overcome 
the  thoracic  rigidity  which  prevents  aeration  of  the  lung. 

Pulmonary  Emphysema.— W.  A.  Freund,  having  recognized  since 
1858  that  some  of  these  cases  are  caused  by  fixation  of  the  chest 
wall  due  to  ossification  of  the  costal  cartilages,  proposed  in  1906 
the  operation  of  chondrectomy  for  their  treatment.  The  costal  cartil- 
ages of  the  second,  third,  and  fourth  ribs  on  both  sides  of  the  thorax 
are  excised  with  their  perichondrium,  so  as  to  prevent  their  regenera- 
tion. The  operation  appears  to  have  been  employed  in  at  least  fifty 
cases,  with  a  fair  measure  of  success. 

Abscess  and  Gangrene  of  the  Lung,  which  are  not  very  frequent, 
may  be  regarded  as  different  stages  of  the  same  affection.     Most 


SOO  SURGERY  OF  THE  LUNGS   AND  PLEURA 

cases  occur  in  adults,  and  follow  the  lodgement  of  foreign  bodies. 
Numerous  cases  following  inspiration  of  blood  or  pus  during  tonsil- 
lectomies under  general  anesthesia  have  been  reported.  Some  follow 
a  pulmonary  infarct  from  a  septic  focus  elsewhere  in  the  body. 

Most  cases  of  so-called  abscess  of  the  lung  develop  from  encapsu- 
lated empyemas  and  follow  pneumonia;  they  are  pleural  vomicas 
(Fig.  840). 

Symptoms.- — Usually  these  develop  rather  suddenly  as  a  compli- 
cation of  the  preexisting  disease.  There  is  profound  sepsis.  Physical 
examination  reveals  a  localized  consolidation  in  the  lung,  which  may 
give  the  signs  of  cavity  after  expectoration  of  its  contained  sputum. 
The  sputum  from  an  abscess  is  great  in  quantity,  and  consists  of 
thick  yellow  pus,  not  malodorous  at  first.  The  older  the  abscess 
the  more  fetid  does  the  pus  become,  owing  to  saprophytic  infection. 
In  cases  of  gangrene,  which  usually  is  a  sequel  to  abscess  formation, 
this  fetid  character  of  the  pus  is  very  pronounced.  If  there  is  elastic 
tissue  in  the  sputum  it  is  not  probable  that  gangrene  is  present, 
since  saprophytic  bacteria  soon  destroy  it.  Pleurisy,  with  adhesions, 
frequently  occurs  and  may  prevent  perforation  of  the  abscess  into 
the  pleural  cavity  with  development  of  a  putrid  empyema.  The  use 
of  the  .r-ray  is  of  much  value  in  localizing  the  abscess.  If  exploratory 
puncture  is  done,  it  should  be  followed  at  once  by  operation. 

Treatment. — Operation  should  not  be  delayed  if  gangrene  is  pres- 
ent. The  patient  gets  no  stronger  by  waiting  even  for  one  day. 
Without  operation  80  per  cent,  of  cases  of  gangrene  of  the  lung 
die.  In  Korte's  28  operations  for  abscess  or  gangrene,  the  mor- 
tality was  28.5  per  cent.  (1908).  In  Lenhartz's  111  operations 
for  gangrene  the  mortality  varied  from  27  to  38  per  cent.  (1909). 
If  the  abscess  drains  well  through  a  bronchus,  operation  may  be  post- 
poned. Whenever  possible  the  operation  should  be  done  under  local 
anesthesia  or  by  anesthesia  by  intratracheal  insufflation.  The  ribs 
overlying  the  site  of  the  abscess  (which  should  be  determined  before- 
hand) are  resected  subperiosteally,  for  a  distance  of  8  to  10  cm.  Some- 
times the  site  of  the  abscess  can  be  detected  by  palpation,  being  denser 
than  the  surrounding  lung  tissue.  If  the  patient  is  not  in  very  serious 
condition,  the  second  stage  of  the  operation  is  postponed  for  a  couple 
of  days,  the  lung  being  sutured  to  the  pleura  by  interrupted  sutures  of 
chromic  gut,  applied  in  a  circle  around  the  supposed  site  of  the  abscess. 
If  the  lung  is  already  adherent  to  the  parietal  pleura,  or  if  the  patient's 
condition  is  precarious,  the  surgeon  proceeds  at  once  to  open  the  lung. 
This  is  done  by  Hilton's  method,  first  thrusting  a  grooved  director  into 
the  lung,  and  when  pus  is  found  dilating  the  tract  with  dressing 
forceps.  Some  surgeons  use  the  actual  cautery  for  opening  the  abscess. 
Any  loose  necrotic  masses  of  lung  tissue  should  be  removed,  but  if 
even  lightly  adherent  they  should  not  be  disturbed  The  abscess  is 
drained  by  a  tube. 

Bronchiectasis. — Though  this  condition  is  not  curable  by  medical 
means,  the  cure  by  surgery  may  be  worse  than  the  disease.    The 


STAB  WOUNDS  OF  THE  DIAPHRAGM  801 

persistence  of  the  bronchiectatic  cavity  may  not  materially  shorten  the 
patient's  life,  and  the  risk  of  operation  is  great.  The  least  dangerous 
and  most  promising  form  of  surgical  treatment  consists  in  some  form 
of  extrapleural  thoracoplasty,  to  cause  collapse  of  the  diseased  lung. 

Tumors  of  the  Pleura  and  Lung  may  be  primary,  or  secondary 
to  growths  elsewhere.  Primary  growths  are  rare  and  very  difficult 
to  diagnose.  Most  of  them  are  malignant  in  nature.  Endothelioma 
and  sarcoma  occur  in  both  lung  and  pleura,  carcinoma  only  in  the 
lung.  Tumors  of  the  pleura  invade  the  lung,  and  those  of  the  lung 
soon  attack  the  pleura.  Of  the  secondary  growths  carcinoma  is  more 
frequent  than  sarcoma. 

Symptoms. — The  symptoms  are  not  clearly  defined.  Some  cases  of 
primary  carcinoma  of  the  lung  are  mistaken  for  tuberculosis.  There 
is  dulness  on  percussion,  and  the  breath  sounds  are  absent  or  may  be 
heard  distantly.  Exploratory  puncture  may  reveal  a  bloody  pleural 
effusion,  or  there  may  be  a  dry  tap.  Blood  in  a  pleural  effusion  signi- 
fies either  tuberculosis  or  malignant  disease.  There  is  no  fever  and 
no  leukocytosis.  The  increase  in  the  physical  signs  is  rapid.  Cachexia 
appears  early  and  is  pronounced. 

Treatment. — There  is  little  to  do.  If  the  pleura  fills  with  fluid, 
and  this  causes  dyspnea,  thoracentesis  may  be  done.  A  few  cases 
of  excision  of  portions  of  the  lung  have  been  recorded,  the  patients 
surviving  the  operation  (Lenhartz). 

SURGERY  OF  THE  DIAPHRAGM. 

Stab  Wounds  of  the  Diaphragm. — In  the  majority  of  cases  the 
stab  wound  is  received  in  the  thorax,  by  a  downward  thrust,  and  a 
complicating  wound  of  the  pleura  exists.  This  is  almost  always  the 
case  in  stab  wounds  inflicted  by  Slavs,  but  Italians  frequently  stab 
their  antagonists  by  an  upward  thrust,  the  stiletto  entering  the 
abdomen  first.  The  left  side  is  more  often  injured  than  the  right. 
There  are  no  characteristic  symptoms,  and  the  diagnosis  can  be  made 
with  certainty  only  by  exploratory  operation,  except  in  the  rather 
unusual  cases  in  which  the  omentum  or  one  of  the  abdominal  viscera 
protrudes  through  the  thoracic  wound.  It  is  the  frequency  of  injury 
to  the  abdominal  contents  which  renders  these  wounds  so  serious. 
In  55  out  of  121  consecutive  stab  wounds  of  the  thorax,  recorded  by 
Lawrow  (1911),  the  diaphragm  and  abdominal  organs  were  involved. 
The  wound  usually  is  in  one  of  the  lower  intercostal  spaces,  espe- 
cially between  the  seventh  and  tenth;  but  stab  wounds  as  high  as  the 
second  interspace  have  caused  injury  to  the  diaphragm.  The  liver 
is  the  most  frequently  injured  of  the  abdominal  viscera,  then  the 
stomach  or  spleen  (Magula,  1910). 

Treatment. — Treatment  is  by  immediate  exploratory  operation  in 

every  case  in  which  a  lesion  of  the  diaphragm  is  suspected.    The 

mortality  without  operation  is  nearly  90  per  cent.,  and  those  patients 

who  have  survived  the  immediate  injury  have  perished  eventually 

51 


802  SURGERY  OF  THE  DIAPHRAGM 

from  strangulation  of  a  diaphragmatic  hernia  or  other  lesion  which 
a  prompt  operation  could  have  prevented.  Thoracotomy  is  the  oper- 
ation of  choice,  because  by  laparotomy  it  is  very  difficult  if  not  impos- 
sible (1)  to  reduce  the  herniated  organs,  owing  to  the  negative  pressure 
within  the  thorax,  (2)  to  repair  the  wound  of  the  diaphragm,  (3)  to 
suture  wounds  of  the  cardia  or  fundus  of  the  stomach,  or  (4)  to  repair 
damage  to  the  lung.  The  technique  of  the  operation  is  much  the  same 
as  that  for  diaphragmatic  hernia  (p.  803).  If  the  stab  wound  is 
abdominal,  and  laparotomy  is  employed  as  the  primary  operation, 
secondary  thoracotomy  may  be  necessary  before  the  herniated  organs 
can  be  replaced  or  the  diaphragm  sutured;  such  an  operation  is 
described  as  thoracolaparotomy.  By  the  term  combined  operation 
is  understood  one  in  which  the  thoracic  and  abdominal  cavities  are 
opened  by  the  same  incision:  this  is  best  made  in  the  eighth  inter- 
space, dividing  the  ninth  costal  cartilage  and  the  diaphragm  as  far  as 
necessary  to  secure  free  exposure. 

If  the  case  is  not  complicated  by  injury  to  the  viscera,  the  mortality 
with  prompt  operation  is  less  than  20  per  cent.;  in  complicated  cases 
it  is  about  65  per  cent.  (Magula). 

Gunshot  Wounds  of  the  Diaphragm,  except  when  complicated  by 
injury  to  the  viscera,  are  so  rare  as  to  have  little  surgical  interest, 
unless  strangulation  of  a  hernia  occurs  subsequently  through  the 
opening  in  the  diaphragm.  In  most  cases  injuries  of  the  thoracic 
and  abdominal  organs  exist,  and  the  surgeon  has  to  employ  either 
thoracolaparotomy  or  the  combined  operation. 

Rupture.  —  Rupture  of  the  diaphragm,  a  subcutaneous  injury,  is 
very  rare.  As  extensive  lesions  of  the  abdominal  organs  are  frequent, 
it  is  best  to  employ  laparotomy  as  the  primary  operation,  so  that 
hemorrhage  and  intestinal  leakage  may  be  controlled.  If  it  is  diffi- 
cult to  reduce  the  organs  which  have  been  herniated  into  the  thorax, 
thoracotomy  should  be  done  also;  this  usually  is  required  to  facilitate 
repair  of  the  diaphragm. 

Diaphragmatic  Hernia  may  be  due  either  to  congenital  or  to  trau- 
matic defect  in  the  diaphragm.  Owing  to  the  negative  pressure 
within  the  thorax,  it  is  always  the  abdominal  organs  which  prolapse 
through  the  opening.  The  most  frequently  herniated  viscera  are 
the  stomach,  colon,  omentum,  small  intestine,  liver,  duodenum, 
and  kidney — in  the  order  named.  Though  a  congenital  defect  may 
be  present  at  birth,  the  hernia  may  not  appear  until  adult  life,  and 
may  produce  no  noteworthy  symptoms  until  strangulation  occurs. 
In  over  90  per  cent,  of  cases  the  hernia  is  on  the  left  side,  because  the 
liver  acts  as  a  protection  on  the  right.  Most  of  the  cases  occur  in 
the  fetus,  or  in  infants  stillborn  or  dying  soon  after  birth.  In  adult 
life  sudden  death  from  cardiac  failure  is  a  frequent  termination, 
and  the  possibility  of  a  diaphragmatic  hernia  always  should  be  re- 
membered in  considering  the  causes  of  sudden  death. 

Symptoms. — Subjective  symptoms  often  are  lacking,  the  malfor- 
mation  being  found   unexpectedly   at   autopsy.      In   the   newborn, 


DIAPHRAGMATIC  HERNIA  803 

cyanosis  and  dyspnea  are  prominent,  the  left  thorax  does  not  expand 
properly,  there  is  dextrocardia,  and  death  usually  results  in  a  few 
hours.  The  adult  patient  may  have  suffered  from  mild  indigestion, 
with  distress  after  meals;  but  no  alarming  symptoms  may  arise  until 
sudden  cardiac  failure  or  perhaps  death  occurs  from  acute  over- 
distention  of  the  herniated  stomach.  Strangulation  is  a  frequent 
termination,  being  due  to  any  sudden  strain  which  forces  a  larger 
portion  of  the  abdominal  contents  through  the  diaphragmatic  opening. 

The  physical  signs  of  diaphragmatic  hernia  are  much  more  precise 
in  theory  than  in  practice.  Diagnosis  of  the  condition  in  life,  except 
by  the  aid  of  the  z-ray,  is  exceptional.  The  lower  chest  on  the 
affected  side  is  tympanitic,  the  breath  sounds  are  very  feeble  and 
distant,  vocal  fremitus  is  lost,  expansion  is  decreased,  and  the  heart 
is  dislocated  away  from  the  affected  side.  The  same  signs  exist  in 
pneumothorax;  but  in  diaphragmatic  hernia  the  diaphragm  does 
not  descend  on  deep  inspiration,  and  causes  which  may  produce 
pneumothorax  nearly  always  may  be  absolutely  excluded.  Moreover, 
distention  of  the  stomach  with  liquid  will  change  the  physical  signs 
in  a  case  of  diaphragmatic  hernia;  but  in  pneumothorax  the  thoracic 
tympany  and  other  signs  will  not  be  affected.  Aspiration  is  to  be 
condemned  as  a  method  of  diagnosis,  owing  to  the  great  danger  of 
septic  pleuritis  or  peritonitis.  A  history  of  sudden  onset  following 
severe  strain  (sometimes  childbirth)  or  crushing  injury,  or  occurring 
some  years  after  a  stab  or  gunshot  wound  of  the  thorax,  is  highly 
characteristic  of  diaphragmatic  hernia.  Finally  the  relation  of  the 
stomach  to  the  diaphragm  may  be  determined  by  the  use  of  skiagraphy 
after  filling  the  stomach  with  an  opaque  meal  or  introducing  a 
stomach  tube  filled  with  mercury.  From  the  rare  congenital  con- 
dition known  as  eventration  of  the  diaphragm,  which  is  associated  with 
hypoplasia  of  the  left  lung,  diaphragmatic  hernia  sometimes  may  be 
distinguished  by  the  history  of  the  case,  and  by  recognizing  through 
skiagraphy  that  the  diaphargm  in  the  former  condition  remains 
still  above  the  abdominal  organs  no  matter  how  far  upward  into  the 
thoracic  cavity  these  may  protrude. 

Treatment. — Immediate  operation  is  required  for  recent  diaphrag- 
matic hernia  of  sudden  development,  because  the  danger  of  strangu- 
lation is  very  great.  Unfortunately  most  such  cases  are  first  seen  by 
the  surgeon  after  strangulation  has  developed,  and  the  patient  is  too 
ill  to  justify  the  prolonged  examination  and  numerous  tests  recom- 
mended in  seeking  to  reach  a  correct  diagnosis.  But  if  the  surgeon 
can  ascertain  that  the  patient  has  had  a  severe  injury  (crush,  or  pene- 
trating wound  of  the  lower  thorax  or  upper  abdomen)  even  many 
years  previously,  the  diagnosis  and  indications  for  treatment  may 
become  very  apparent.  If  the  true  condition  is  recognized  thoracotomy 
(Permann  and  Postempski,  1889)  should  be  done.  In  many  cases  inci- 
sion in  the  eighth  intercostal  space,  without  resection  of  ribs,  has  given 
adequate  exposure.  After  packing  off  the  lung  with  gauze  tampons, 
any  rupture  or  perforation  of  the  abdominal  viscera  should  be  repaired, 


804  SURGERY  OF  THE  DIAPHRAGM 

and  they  should  be  replaced  within  the  abdominal  cavity.  Then  the 
opening  in  the  diaphragm  should  be  sutured;  when  this  is  not  possible 
the  omentum  may  be  stitched  to  its  margins,  or  as  a  last  resort  the 
opening  may  be  tamponed.  If  the  operation  has  been  done  under 
differentia]  pressure  or  with  intratracheal  insufflation  anesthesia,  the 
lung  should  be  expanded  at  the  close  of  the  operation,  and  the  pleura 
may  be  closed  without  drainage.  In  other  cases  a  tube  should  be  left 
in  for  a  few  days. 

If  no  diagnosis  other  than  intestinal  obstruction  has  been  made, 
laparotomy  will  be  the  operation-  employed;  but  if  reduction  of  the 
hernia  from  below  proves  impossible,  no  hesitation  should  be  felt 
in  proceeding  to  thoracotomy. 


CHAPTER  XXI. 
HERNIA. 

A  hernia  is  a  protrusion  of  a  viscus  through  an  abnormal  opening 
in  the  walls  of  the  cavity  within  which  it  is  naturally  contained.  This 
is  a  general  definition,  and  may  be  applied  to  a  hernia  of  a  muscle 
through  a  rupture  in  its  sheath,  to  a  hernia  of  the  brain  through  an 
artificial  opening  in  the  skull,  or  to  a  hernia  of  an  abdominal  viscus 
through  an  abnormal  opening  in  the  abdominal  walls.  By  long 
usage,  however,  the  term  hernia,  when  standing  by  itself,  is  applied 
only  to  protrusions  of  the  abdominal  viscera.  This  protrusion  usually 
occurs  through  an  aperture  of  the  abdominal  wall  which  transmits 
bloodvessels  or  nerves,  through  a  congenital  defect,  or  through  one 
acquired  as  the  result  of  operation  or  disease.  If  this  protrusion  occurs 
through  a  normal  opening  it  is  not  called  a  hernia,  but  a  prolapse; 
as  a  prolapse  of  the  rectum  through  the  anus,  or  of  the  uterus  through 
the  vagina.  The  term  hernia  also  implies  that  the  protruding  struc- 
tures are  still  covered  by  skin :  thus  when  omentum  or  other  structure 
protrudes  through  an  incised  wound  of  the  abdomen,  it  is  not  called 
a  hernia  but  a  prolapse. 

In  the  great  majority  of  cases  of  abdominal  hernia,  the  viscus  which 
protrudes  carries  before  it  a  pouch  of  the  parietal  peritoneum,  which 
is  called  the  sac  of  the  hernia ;  and  since  this  sac  may  remain  as  a  pro- 
trusion even  when  it  contains  none  of  the  abdominal  viscera,  a  hernia 
has  been  defined  as  "a  protrusion  of  peritoneum  liable  to  contain, 
containing  at  times,  or  permanently  containing  any  viscus  or  part  of 
a  viscus  from  the  abdominal  cavity."  (Da  Costa.)  But  as  the  abdomi- 
nal organs  sometimes  protrude  through  a  part  of  the  abdominal  wall 
which  has  no  parietal  peritoneum  (e.  g.,  a  hernia  of  the  bladder),  or 
slide  down  behind  the  parietal  peritoneum,  instead  of  carrying  it  before 
them  as  a  protrusion  (e.  g.,  sliding  hernia  of  the  colon),  I  think  it  is 
better  to  cling  to  the  old  definition.  If  the  sac  protrudes  and  is 
empty  that  patient  has  either  a  reduced  or  a  'potential  hernia,  accord- 
ing to  whether  or  not  the  sac  has  before  been  the  seat  of  a  hernia. 
A  sac  may  exist  for  many  years  without  a  hernia  developing  in  it 
(p.  806). 

Nomenclature. — A  hernia  receives  its  name  (1)  from  the  region 
in  which  it  appears,  as  epigastric,  lumbar,  umbilical,  inguinal,  etc.; 
(2)  from  its  contents,  as  a  hernia  of  intestine  (enterocele) ,  of  omentum 
(epiplocele),  of  bladder  (cystocele),  of  rectum  (rectocele),  etc.;  (3) 
from  its  condition,  as  reducible,  irreducible,  inflamed,  strangulated, 
etc. ;  and  (4)  from  its  mode  of  development,  whether  of  sudden  develop- 

(805) 


800  HERNIA 

ment  or  slowly  acquired.  Various  other  terms,  used  in  describing 
hernia,  will  be  explained  as  they  are  encountered. 

Causes. — The  predisposing  causes  of  a  hernia  may  be  either  general 
or  local. 

General  Predisposing  Causes. — -(1)  Age.  Most  hernise  appear  in  infan- 
tile or  early  adult  life;  the  longer  one  lives  the  less  apt  he  is  to  have  a 
hernia.  But  the  number  of  old  people  alive  is  so  much  less  than  that 
of  young  adults  and  children,  that  among  the  aged  hernia  is  relatively 
more  common.  (2)  Sex.  Men  and  boys  are  much  oftener  afflicted 
with  hernia  than  women.  There  are  two  main  reasons  for  this:  first 
because  of  the  weakness  of  the  inguinal  region  in  the  male  sex  from 
the  descent  through  it  of  the  testicle;  and,  second,  from  the  more  active 
life  men  lead,  and  the  greater  frequency  with  which  they  are  sub- 
jected to  great  abdominal  strains.  (3)  A  distinct  hereditary  tendency 
toward  hernia  is  recognized,  probably  from  the  persistence  of  anatomi- 
cal defects  at  points  of  greatest  strain. 

Local  Predisposing  Causes. — (1)  Weakness  of  the  abdominal  wall. 
After  an  abdominal  operation,  a  hernia  may  develop  in  the  scar 
(incisional  hernia,  p.  824) ;  or  as  a  consequence  of  injury  to  the  motor 
nerves  of  the  inguinal  region  from  an  operation  elsewhere,  an  inguinal 
hernia  subsequently  may  develop  (Figs.  859,  872,  and  876).  Some- 
times a  hernia  appears  first  after  a  debilitating  illness  or  pregnancy. 
(2)  Increased  strain  upon  the  parietes  by  the  abdominal  contents.  The 
gradual  deposition  of  fat  in  the  omentum  and  mesentery  increases  the 
intra-abdominal  tension,  causes  stretching  of  the  parietal  peritoneum, 
opens  up  the  hernial  orifices,  and  thus  predisposes  to  the  development 
of  a  hernia.  The  same  train  of  events  may  occur  in  cases  of  ascites, 
of  intra-abdominal  tumors,  of  pregnancy,  etc.  (3)  A  hernia  may  be 
the  effect  of  repeated  efforts,  in  coughing,  in  straining  at  stool,  in  urinat- 
ing (when  there  is  some  urinary  obstruction)  (Fig.  882).  (4)  The 
existence  of  a  congenital  sac  predisposes  the  patient  to  the  develop- 
ment of  a  hernia,  though  observations  in  the  dissecting  room  show 
that  many  patients  with  preformed  sacs  pass  through  life  without 
any  evidence  of  a  hernia. 

Structures  Composing  a  Hernia. — In  a  typical  case  a  hernia  is 
composed  of  a  pouch  of  parietal  peritoneum,  called  the  sac;  of  the 
contents  of  the  sac;  and  of  its  coverings,  which  are  the  structures  of 
the  abdominal  wall,  muscles,  fascia,  and  skin  (Fig.  848). 

Sac. — The  sac,  as  noted  already,  sometimes  is  wholly  or  in  part 
deficient.  Typically  it  is  composed  of  a  neck  (that  part  which  com- 
municates with  the  peritoneal  cavity),  and  a  body  (that  part  which 
surrounds  the  protruding  viscera).  The  apex  of  the  sac  is  its  fundus. 
The  sac  may  be  congenital  or  acquired.  I  believe,  with  Russell  and 
Murray  (1899),  that  the  sac  is  congenital  in  afar  larger  proportion  of 
cases  than  is  commonly  thought.  This  preformed  sac  renders  the  pat- 
ient the  potential  possessor  of  a  hernia;  but  until  the  hernia  develops 
("comes  down"  is  the  colloquial  expression),  the  presence  of  the  sac 
in  most  cases  cannot  be  determined  (p.  1115,  congenital  hydrocele). 


STRUCTURES  COMPOSING  A  HERNIA 


807 


Peritoneum 


Transvtrsalis  fascia 


Muscle 


Skin  &.  Sup.  fascia. 


Fig.  848. — Diagram  to  show  a  hernial 
sac,  its  contents  and  coverings. 


The  congenital  sac  is  found  oftenest    in  femoral  hernia,  but  occurs 

frequently  also  in  the  inguinal  form,  and  sometimes  in    umbilical 

hernia.    It  may  be  very  large,  but  usually  is  quite  small  until  distended 

by  the  protruding  abdominal  contents.     The  acquired  sac  usually  is 

slowly  developed  from  gradual  stretching  of  the  parietal  peritoneum: 

at  first  the  neck  of  the  acquired  sac  is  its  widest  part,  but  as  the  sac 

increases  in  size  it  becomes  more 

or    less    pear-shaped,    the    neck 

being  relatively  narrow;  then  the 

sac  continues  to  increase  in  size 

by  the  pressure  of  the  contained 

structures,  but,  as  a  rule,  the  neck 

does  not  enlarge  at  the  same  rate 

but  remains  relatively  small.  The 

wall  of  the  sac,  at  first  like  the 

neighboring  parietal  peritoneum 

may  become  much  thickened  from 

inflammation,  and  its  neck  may 

undergo    cicatricial    contraction. 

The  sac  usually  becomes  densely 

adherent  to  the  surrounding  parts, 

especially    at    its    fundus;    and 

though  the   contents   of  the  sac  may  be  returned  to  the  abdomen, 

as  long  as  the  empty  sac  remains  recurrence  of  the  hernia  is  to  be 

expected.    In  hernia  of  long  duration   the   neck  of  the  sac  may  be 

shifted,  by  the  pull  of  its  contents,  downward  and  toward  the  median 

line  of  the  body. 

The  Contents  of  the  Sac  may  be  almost  any  of  the  abdominal 
viscera,  but  the  most  frequently  herniated  structures  are  the  intes- 
tine (enterocele),  and  the  omentum  (epiplocele).  In  infancy  and 
young  childhood  the  omentum  seldom  is  found  in  a  hernia,  owing 
to  its  undeveloped  state;  but  in  adults,  particularly  those  who 
are  obese,  it  is  the  most  frequently  found  of  all  structures.  The 
lower  ileum  is  the  portion  of  the  bowel  most  often  found  in  a 
hernia,  because  it  has  the  longest  mesentery  and  lies  nearest  the 
inguinal  and  femoral  openings.  Hernia  of  the  large  bowel  is  infre- 
quent, owing  to  its  relatively  short  mesenteric  attachments.  The 
cecum  may  be  drawn  into  a  hernia  by  a  coil  of  ileum  already  there; 
but  the  sigmoid  is  sufficiently  mobile  to  find  its  own  way  into  a  hernia. 
A  single  coil  or  several  coils  of  intestine  may  be  found  in  the  sac, 
or  the  hernia  may  be  formed  only  by  a  portion  of  the  wall  of  the  intes- 
tine; this  latter  condition  (Fig.  849)  is  described  as  liichters  hernia 
(1778).  A  hernia  of  Meckel's  diverticulum  (Fig.  850)  is  known  as 
Littres  hernia  (1700).  When  the  hernial  contents  remain  long  in  the 
sac,  they  usually  become  adherent  to  its  walls  and  often  are  matted 
together.  In  this  way  a  hernia  may  become  irreducible.  When  both 
omentum  and  intestine  are  in  the  sac  (entero-epiplocele),  it  usually  is 
the  omentum  which  enters  it  first.     The  omentum  generally  lies  in 


808 


HERNIA 


front  of,  or  even  completely  surrounds  the  bowel,  and  the  bowel  may 
be  caught  in  apertures  or  depressions  in  the  mass  of  omentum  and 
thus  may  become  strangulated.  Unless  the  hernia  is  inflamed  or 
strangulated  there  is  little  or  no  serum  within  the  sac. 


Fig.  S49. — Partial  enterocele,  or  Richter's  hernia.     Drawing  made  from  a  case 
of  strangulated  hernia  in  the  Episcopal  Hospital. 

The  Coverings  of  the  sac  will  be  described  in  connection  with  each 
particular  form  of  hernia. 


Fig.  850. — Littre's  hernia — a  hernia  of  one  of  the  intestinal  diverticula 
(Meckel's  diverticulum). 

Reducible  Hernia. — This  is  one  in  which  the  contents  can  be  replaced 
within  the  abdominal  cavity.  It  is  the  most  frequent  variety,  since 
almost  every  hernia  is  reducible  when  it  first  appears,  and  becomes 
irreducible  only  after  the  lapse  of  years.  For  months  or  years  before 
the  hernia  appears  the  patient  may  have  felt  a  weakness  in  the  region 
where  the  protrusion  afterward  develops.  If  the  hernia  develops 
gradually,  there  may  be  at  first  the  merest  bulging  of  the  parts  during 
straining  efforts;  later  a  small  rounded  tumor  may  be  seen.  This  can 
be  reduced  easily  by  the  pressure  of  a  finger,  and  usually  disappears 
spontaneously  when  the  patient  lies  down.  In  cases  of  hernia  present 
at  birth,  or  of  sudden  though  later  development,  or  of  long  duration 
before  seen  by  the  surgeon,  the  protrusion  often  is  of  considerable 


REDUCIBLE  HERNIA  809 

size.  In  time  the  greater  part  of  the  abdominal  contents  may  descend 
into  the  sac. 

The  outline  of  a  hernia  is  more  or  less  rounded  or  oval,  usually 
being  less  broad  at  the  neck  of  the  sac  than  elsewhere.  The  hernia 
increases  in  size  when  the  patient  stands  up,  coughs,  or  strains;  it 
disappears  either  spontaneously  or  by  gentle  pressure  when  he  lies 
down;  and  in  most  cases  it  reappears  again  if  he  once  more  stands 
up  and  coughs.  When  he  coughs  there  usually  is  a  distinct  impulse 
transmitted  to  the  hernia,  and  this  often  can  be  seen  and  almost 
always  can  be  felt. 

Enterocele. — If  the  sac  contains  intestine  only,  the  hernia  is  smooth, 
feels  elastic,  often  gurgles  on  palpation,  and  usually  is  resonant  on 
percussion.  The  impulse  is  well  marked.  Reduction  usually  is 
accompanied  by  a  distinct  gurgle  and  by  a  characteristic  sensation 
well  described  as  a  "flop." 

Epiplocele. — An  omental  hernia  feels  denser,  more  fibrous  or  doughy 
to  the  touch  than  an  intestinal  hernia;  it  is  irregular  in  outline;  gives 
little  or  no  impulse  on  coughing;  and  is  dull  on  percussion.  Reduction 
is  not  accompanied  by  any  gurgle,  nor  by  the  "flop"  so  characteristic 
of  bowel  slipping  back  into  the  abdomen. 

In  the  entero-epiplocele  the  symptoms  of  the  two  separate  forms  are 
combined. 

It  seldom  is  possible  to  ascertain  what  portion  of  the  gut  forms  the 
hernia.  In  umbilical  hernia  the  transverse  colon  is  most  often  found; 
and  in  inguinal  and  femoral  hernia,  the  ileum.  The  cecum  is  much 
more  frequent  in  right-sided  inguinal  hernia  than  elsewhere,  but  is 
not  very  unusual  in  a  left  inguinal  hernia.  In  femoral  hernia  the 
omentum  and  small  bowel  are  most  often  found. 

Treatment. — It  is  necessary  for  a  hernia  to  be  cured,  whenever 
possible,  because  of  the  grave  danger  which  may  accrue  to  the  patient 
from  the  occurrence  of  strangulation.  A  cure  can  be  obtained  only 
by  an  operation,  by  which  the  sac  of  the  hernia  is  removed,  its  neck 
closed,  and  the  structures  of  the  abdominal  wall  repaired  in  such  a 
manner  as  to  prevent  recurrence  of  a  hernia.  This  is  the  best  treat- 
ment in  every  case  in  which  an  operation  is  not  contraindicated ; 
but  the  operation  requires  skill  for  its  performance,  and  sometimes 
is  very  difficult.  It  should  not  be  attempted  by  the  occasional  operator. 
Even  if  the  best  treatment  (that  which  results  in  cure)  is  contra- 
indicated  or  is  refused,  it  is  still  necessary  that  the  hernia  be  treated. 
An  untreated  hernia  tends  constantly  to  grow  larger  and  to  become 
irreducible.  It  is  possible  to  keep  a  hernia  reduced  by  the  use  of 
apparatus  (known  as  a  truss)  which  exerts  pressure  over  the  neck  of 
the  empty  sac,  and  prevents  descent  of  the  hernial  contents.1  It  used 
to  be  taught  that  in  some  cases  the  prolonged  use  of  a  truss  might 
cause  obliteration  of  the  hernial  orifice  by  exciting  adhesions  of  the 

1  I  mention  only  to  condemn  the  attempts  of  some  charlatans  to  cause  closure 
of  the  neck  of  the  hernial  sac  by  injecting  paraffin  in  the  surrounding  tissues 
(Fig.  851). 


810 


HERNIA 


opposing  layers  of  peritoneum.  This  occasionally  occurs  in  infants, 
but  in  the  vast  majority  of  cases,  though  a  truss  may  keep  the  hernia 
reduced  so  long  as  the  truss  is  in  place,  no  obliteration  in  the  neck  of 
the  sac  is  caused,  and  its  contents  tend  to  return  at  once  when  the 
truss  is  removed.  If  the  neck  of  the  sac  becomes  constricted  from 
prolonged  use  of  a  truss  (and  this  is  not  unusual),  the  hernia  will  be 
more  apt  to  become  strangulated,  if  it  comes  down,  than  if  no  truss 

had  been  worn.  If  no  treat- 
ment at  all  is  undertaken,  the 
hernia  constantly  increases  in 
size,  is  very  apt  to  become 
irreducible,  and  the  patient 
must  endure  the  discomforts 
of  this  condition  as  well  as 
run  the  added  risk  of  stran- 
gulation which  an  irreducible 
hernia  entails. 

The  contraindications  to 
operation  in  the  case  of  a 
reducible  hernia  are  only  those 
which  contraindicate  any 
operation,  however  trivial  (p. 
812).  There  are  no  local  con- 
ditions which  contraindicate 
operation  in  cases  of  reduci- 
ble hernia.  Even  immense 
size  of  the  hernial  orifice, 
with  excessively  weak  ab- 
dominal walls,  is  a  condition 
that  may  be  overcome  by 
proper  methods  (p.  826). 
A  truss  is  an  apparatus  designed  to  support  a  hernia.  It  should  keep 
a  reducible  hernia  reduced.  It  is  applied  around  the  body,  and  has  a 
pad  which  makes  pressure  over  the  hernial  orifice.  Most  trusses  are 
for  inguinal  or  femoral  hernia,  and  are  applied  around  the  pelvis 
between  the  iliac  crests  and  the  trochanters  of  the  femora  (Fig.  876). 
A  truss  may  be  made  of  steel  covered  with  leather  or  hard  rubber, 
causing  elastic  pressure  over  the  hernial  orifice;  or  it  may  be  made 
entirely  of  leather,  and  depend  on  the  tension  with  which  it  is  buckled 
in  place  to  retain  the  hernia.  Trusses  are  also  used  for  umbilical 
hernia?;  and  the  abdominal  belts,  used  to  support  ventral  and  inci- 
sional hernia  may  be  considered  a  form  of  truss. 

There  are  certain  features  which  every  truss  should  possess:  it 
should  retain  its  position  without  extraneous  aid;  it  should  keep  the 
hernia  reduced  in  all  positions  of  the  body,  and  during  coughing, 
sneezing,  defecation,  etc.;  it  should  not  cause  irritation  of  the  skin 
overlying  the  hernia  or  elsewhere;  and  it  should  be  easily  kept  clean. 
The  patient  must  have  at  least  two  trusses,  in  case  one  of  them  is 


Fig.  851. — Masses  of  paraffin  in  inguinal 
canal  and  scrotum,  injected  on  two  occasions, 
several  months  ago,  in  an  effort  to  cure  a  hernia 
of  twelve  years'  duration.  Patient  aged  thirty- 
eight  years.  Hernia  now  in  scrotum.  Epis- 
copal Hospital. 


IRREDUCIBLE  HERNIA  811 

broken.  The  trusses  suitable  for  the  different  forms  of  hernia  will 
be  described  under  special  herniae  (p.  837). 

De  Garmo  (1907)  says  a  patient  who  wears  a  truss  is  a  chronic  in- 
valid, and  though  this  statement  is  somewhat  of  an  exaggeration,  it  is 
absolutely  true  that  such  a  patient  must  observe  certain  rules  of  con- 
duct if  he  wishes  to  continue  in  good  health.  He  should  be  kept  under 
his  physician's  observation.  A  truss  requires  as  strict  oversight  as 
any  other  orthopedic  appliance  (p.  561).  The  truss  must  always  be 
applied  while  the  patient  is  recumbent,  after  reduction  of  the  hernia; 
it  need  not  be  worn  at  night,  but  it  should  be  reapplied  every  morning 
before  the  patient  gets  out  of  bed.  It  must  never  be  taken  off  except 
when  he  is  lying  down.  When  he  takes  a  bath  he  must  wear  the  truss 
in  the  tub.  He  must  not  make  any  sudden  exertion  or  strain  at  any 
time.  He  must  lift  no  heavy  weights.  He  must  not  go  swimming. 
He  should  be  debarred  from  all  athletics  except  the  lightest  exercises. 
If  he  wants  to  be  cured  of  his  hernia,  let  him  be  operated  on.  Other- 
wise he  must  endure  the  limitations  which  truss-wearing  requires. 
The  possibility  of  strangulation  of  his  hernia  should  be  ever  present 
in  his  mind.  Should  it  occur  it  will  force  him  almost  always  to  an 
immediate  operation  to  escape  death;  and  he  will  be  unable  to 
choose  either  the  time,  or  the  place,  or  the  surgeon  for  such  an 
operation. 

Irreducible  Hernia. — The  commonest  causes  for  irreducibility  of  a 
hernia  are  inflammatory  adhesions  affecting  its  contents.  These  may 
be  between  the  sac  and  its  contents,  or  adhesions  of  the  coils  of  bowel 
to  each  other,  to  the  omentum,  etc.  The  most  frequent  cause  is 
adhesion  of  the  omentum  to  the  sac.  The  bowel  rarely  becomes 
adherent  to  the  sac. 

Intravisceral  adhesions  often  prevent  reduction  even  when  no 
adhesions  to  the  sac  wall  exist,  because  the  contents  are  amal- 
gamated into  a  mass  too  large  to  pass  through  the  neck  of  the 
sac.  A  hernia  may  be  apparently  irreducible,  because  manipulation 
cannot  force  back  in  a  short  time,  through  a  small  orifice,  a  large 
mass  of  intestines  or  omentum  which  have  taken  years  to  descend. 
There  is  no  strangulation  present  in  an  irreducible  hernia,  though  a 
strangulated  hernia  may  be  irreducible.  The  diagnosis  of  an  irre- 
ducible hernia  depends  upon  recognizing  that  the  protrusion  is  at  one 
of  the  usual  hernial  orifices,  on  ascertaining  the  history  of  its  develop- 
ment, and  on  the  physical  signs,  which  are  the  same  as  in  a  reducible 
hernia,  with  a  few  self  evident  exceptions.  An  irreducible  hernia 
presents  an  impulse  on  coughing;  it  constantly  tends  to  become  larger, 
and  the  patient  suffers  from  a  sense  of  dragging,  from  digestive  dis- 
turbances, and  often  from  intermittent  attacks  of  constipation  and 
diarrhea.  Though  a  patient  may  live  for  many  years  with  an  irre- 
ducible hernia,  he  is  in  constant  peril  because  the  prolapsed  viscera 
are  exposed  to  trauma,  and  are  liable  to  repeated  attacks  of  inflam- 
mation or  obstruction;  and  strangulation  is  much  more  apt  to  occur 
than  in  the  case  of  a  hernia  which  is  retained  by  a  truss. 


812  HERNIA 

Treatment. — The  cure  of  an  irreducible  hernia  is  more  difficult  and 
dangerous  than  that  of  a  simple  hernia,  and  can  be  secured  only  by 
operation.  Except  in  the  very  old,  or  those  with  severe  constitutional 
or  organic  disease,  or  those  with  most  enormous  hernise,  operation 
always  should  be  urged  upon  the  patient.  It  is  extremely  desirable 
to  reduce  the  size  of  these  large  hernise  before  any  operation  is  under- 
taken, and  even  if  no  operation  is  done  the  patient  may  secure  much 
relief  from  the  preliminary  treatment.  This  plan  is  to  keep  the  patient 
in  bed,  on  spare  diet,  with  a  course  of  mild  purging,  and  frequent 
enemas,  so  as  to  secure  complete  evacuation  of  the  bowels.  Absti- 
nence and  rest  will  reduce  the  amount  of  fat  in  the  omentum  and 
mesentery;  and  recumbency,  combined  with  elevation  of  the  foot 
of  the  bed,  will  bring  the  force  of  gravity  to  aid  in  securing  reduction 
in  the  size  of  the  hernia.  This  method  appears  first  to  have  been 
advocated  by  Sir  Astley  Cooper  in  1828.  In  most  cases  a  partial  reduc- 
tion at  least  can  be  secured  by  resort  to  taxis  (p.  818)  after  a  couple  of 
weeks  of  this  preparatory  treatment,  and  sometimes  the  entire  hernia 
can  be  reduced.  In  these  cases  of  immense  hernia,  if  the  surgeon 
thoughtlessly  undertakes  an  operation  without  such  preparatory 
treatment,  he  may  find  it  impossible  to  make  the  viscera  enter  the 
abdomen  even  after  this  has  been  opened.  If  the  hernia  can  be 
reduced  to  ordinary  size  before  operation  is  attempted,  this  should 
be  as  successful  in  obtaining  a  cure  as  in  cases  of  reducible  hernia. 

If  the  patient  refuses  operative  treatment,  the  application  of  some 
form  of  support,  in  the  nature  of  a  "bag-truss"  or  suspensory  may 
somewhat  alleviate  the  symptoms. 

Inflamed  and  Obstructed  Hernia. — These  conditions  are  met  with 
almost  solely  in  cases  of  irreducible  hernia.  Inflammation  may  occur 
from  accidental  trauma,  from  unskilled  or  violent  attempts  at  reduc- 
tion, from  the  pressure  of  an  ill-fitting  truss,  or  from  changes  in  the 
contents  of  the  sac.  Among  the  latter  attention  may  be  called  to 
the  occasional  presence  of  the  vermiform  appendix  in  the  sac,  with  the 
possibility  of  appendicitis.  Obstruction  of  a  hernia  is  said  to  occur 
when  the  normal  course  of  gas  or  feces  through  the  herniated  bowel  is 
interrupted;  this  may  result  from  intestinal  indigestion  with  accumu- 
lation of  flatus,  or  from  fecal  impaction  (p.  942).  The  symptoms  of 
inflamed  and  obstructed  hernia  are  much  the  same,  consisting  in 
local  pain,  tenderness,  nausea,  and  perhaps  vomiting;  the  hernia  still 
gives  an  impulse  on  coughing;  and  flatus  is  passed  by  the  anus,  though 
there  may  be  constipation.  The  symptoms  are  decidedly  less  severe 
than  in  the  case  of  strangulation. 

Treatment.— The  patient  should  be  put  to  bed,  and  should  lie  in  a 
position  which  relaxes  the  hernial  orifice;  an  ice  bag  should  be  applied 
locally;  an  enema  should  be  administered;  nothing  whatever  should 
be  given  by  mouth;  and  if  the  symptoms  are  severe  or  if  they  do  not 
subside  in  the  course  of  three  or  four  hours,  operation,  as  in  cases  of 
strangulation,  becomes  imperative.  In  any  case  where  the  condition 
of  strangulation  cannot  be  positively  excluded,  immediate  operation 
should  be  done. 


STRANGULATED  HERNIA  813 

Incarcerated  Hernia. — This  is  one  which,  though  ordinarily  re- 
ducible, has  for  some  reason  become  temporarily  irreducible  (De 
Garmo).  This  complication  occurs  most  often  in  large  hernise,  and 
usually  is  due  to  unskilful  attempts  at  reduction,  resulting  in  some 
slight  twist  in  the  bowel  which  renders  the  hernial  orifice  relatively 
too  small  to  allow  reduction.  While  there  may  be  some  local  pain 
and  tenderness,  there  are  no  symptoms  of  strangulation  present. 

Treatment. — Treatment  consists  in  rest  in  bed,  with  the  foot  of  the 
bed  elevated  and  the  patient  so  placed  as  to  relax  the  hernial  orifice. 
An  ice  bag  or  cold  coil  should  be  applied  to  the  hernia,  and  the  surgeon 
should  not  attempt  to  reduce  the  hernia  until  the  acute  symptoms 
have  had  a  chance  to  subside;  he  may  find  then  that  the  hernia  has 
been  spontaneously  reduced,  or  that  its  reduction  by  taxis  (p.  818)  is 
easy.  If  the  symptoms  do  not  subside  within  a  few  hours,  taxis  should 
be  tried,  and  if  this  fails,  operation  should  be  done  as  in  cases  of 
strangulated  hernia. 

Strangulated  Hernia. — This  is  one  in  which  the  circulation  of  blood 
is  obstructed  or  entirely  arrested.  This  serious  occurrence  is  liable 
to  bring  on  all  the  usual  consequences  of  strangulation,  which  are 
studied  at  p.  814. 

The  cause  of  strangulation  of  a  hernia  is  not  always  evident.  It 
is  clear  that  a  constriction  exists,  pressing  upon  the  protruded  struc- 
tures and  interfering  with  their  circulation.  This  constriction  may  be 
either  in  the  sac  wall,  in  the  surrounding  structures,  or  inside  of  the 
sac.  Constriction  by  the  sac  itself  is  rare,  especially  in  children;  the 
site  of  constriction  usually  is  at  the  neck  of  the  sac,  particularly  in 
the  case  of  patients  who  have  long  worn  a  truss  and  in  whom  the  sac 
and  its  neck  have  undergone  cicatricial  contraction.  In  some  cases  of 
congenital  sacs  points  of  constriction  may  exist  elsewhere  than  at  the 
neck  (Fig.  864) ;  and  in  some  cases  constriction  may  occur  from  bands 
of  inflammatory  adhesions  formed  within  the  sac.  Extra-saccular 
constriction  is  by  far  the  most  frequent  form  and  usually  occurs  at  the 
abdominal  opening  in  fascial  or  tendinous  tissue  through  which  the 
sac  and  its  contained  viscera  pass.  Intra-saccular  constriction,  which 
is  rarest  of  all,  may  be  due  to  torsion  of  the  contents  of  the  sac,  or  to 
the  bowel  being  caught  in  an  aperture  or  pocket  in  the  omentum. 

Mechanism  of  Strangulation. — As  the  neck  of  the  sac  and  the  abdomi- 
nal opening  through  which  the  hernia  passes  are  not  muscular,  but 
fibrous,  and  hence  have  no  power  of  active  contraction,  it  is  evident 
that  in  cases  of  extra-saccular  as  in  those  of  intra-saccular  constriction 
the  prime  cause  of  strangulation  lies  in  the  contents  of  the  sac.  If 
the  hernia  previously  was  reducible,  these  changes  in  the  contents 
of  the  sac  usually  begin  as  the  state  already  described  as  incarcera- 
tion of  the  hernia;  in  the  case  of  irreducible  hernia  the  first  changes 
usually  are  those  described  as  inflammation  or  obstruction  of  the  hernia, 
and  they  may  be  brought  on  by  the  unwelcome  intrusion  into  the 
sac  of  a  coil  of  gut  or  a  plug  of  omentum  never  before  present.  In 
some  patients  a  hernia  which  is  suddenly  developed  becomes  stran- 


S 1  I  HERNIA 

gulated  immediately  on  its  first  appearance;  such  a  strangulation  is 
apt  to  cause  rapid  and  very  serious  changes  in  the  contents  of  the  sac. 
A  similar  chain  of  events  usually  occurs  when  a  hernia  suddenly  pro- 
trudes into  a  sac  which  has  long  been  empty,  especially  if  the  use  of 
a  truss  has  caused  cicatricial  contraction  in  the  neck  of  the  sac.  This 
form  of  strangulation  may  he  described  as  acute  to  distinguish  it  from 
that  of  more  chronic  onset,  which  usually  is  preceded  by  incarceration, 
inflammation,  or  obstruction  of  the  hernia. 

All  irreducible  hernias  are  more  liable  to  strangulation  than  those 
which  are  reducible  and  are  retained  by  a  truss.  An  irreducible 
umbilical  hernia  is  especially  liable  to  strangulation;  and,  of  all  forms, 
a  femoral  hernia  is  most  prone  to  strangulation.  Ventral  and  inci- 
sional hernias  very  rarely  become  strangulated. 

Structural  Changes  Occurring  in  Strangulation. — Probably  in  every 
case  the  first  change  is  obstruction  of  the  venous  circulation  of  the 
contents  of  the  sac;  the  arterial  circulation  is  less  rapidly  affected 
because  of  the  higher  blood-pressure  in  the  arteries  and  their  more 
resistant  walls.  Arrest  of  the  venous  circulation  causes  the  blood  to 
be  dammed  back  into  the  capillaries  while  these  are  still  receiving 
blood  from  the  arterial  side.  The  result  is  stagnation  of  the  blood, 
and  edema  of  the  extra  vascular  tissues.  Almost  at  once  the  hernia 
becomes  too  large  to  be  returned  through  the  orifice  by  which  it  had 
escaped.  If  intestine  is  strangulated,  intestinal  obstruction  (p.  937) 
is  present  as  well  as  strangulation,  and  usually  precedes  it. 

Strangulation  of  bowel  causes  the  rapid  outpouring  of  serum  which 
may  distend  the  sac;  it  will  be  greater  in  amount  if  the  strangulation 
is  very  slow  in  onset  than  if  the  entire  circulation  is  arrested  immedi- 
ately. At  first  this  fluid  is  pale  yellow,  clear,  and  sterile,  and  perhaps 
should  be  considered  a  transudate  rather  than  an  effusion;  but  very 
soon  it  becomes  inflammatory  in  character,  turning  cloudy  from  the 
increase  in  the  number  of  leukocytes  present,  and  often  is  bloody, 
and  in  later  stages  of  strangulation,  brownish  or  black.  Bacteria  soon 
penetrate  the  walls  of  the  obstructed  bowel.  If  the  strangulation  is 
not  promptly  relieved,  the  bowel,  which  at  first  is  congested,  bright 
red,  soggy,  and  with  its  natural  luster  but  slightly  impaired,  becomes 
purplish  or  even  black  in  color,  and  may  be  covered  with  patches  of 
inflammatory  lymph.  Actual  gangrene  quickly  follows:  the  intestine 
loses  its  luster  entirely,  and  becomes  soft,  doughy,  and  grayish  black; 
the  peritoneal  coat  strips  easily,  the  muscular  coats  are  friable,  and 
the  bowel  is  very  easily  torn.  In  many  cases  definite  rings  of  con- 
striction are  found  at  the  points  of  strangulation:  usually  the  con- 
striction ring  at  the  distal  (anal)  end  of  the  strangulated  loop  is  more 
pronounced  than  that  at  the  proximal  (gastric)  end.  The  bowel 
below  the  constriction  is  nearly  normal  in  appearance,  or  if  anything 
rather  paler  than  normal  and  collapsed;  that  proximal  to  the  constric- 
tion is  distended,  congested,  and  more  nearly  resembles  the  gut  which 
has  occupied  the  hernial  sac.  When  the  bowel  becomes  necrotic,  or 
even  before,  merely  as  the  result  of  intestinal  obstruction,  death  from 


STRANGULATED  HERNIA  815 

toxemia  may  occur.  If  life  is  prolonged,  the  slough  may  separate 
from  the  intestine,  resulting  in  intestinal  perforation  into  the  hernial 
sac,  which  then  becomes  the  seat  of  a  fecal  abscess.  The  overlying 
tissues  may  next  become  inflamed,  and  in  rare  instances  this  fecal 
abscess  has  opened  spontaneously  through  the  skin.  In  many  cases 
septic  inflammation  spreads  to  the  peritoneal  cavity,  and  general 
peritonitis  is  the  cause  of  death.  This  may  occur  from  perforation 
of  the  bowel  at  the  point  of  constriction  (Fig.  852),  with  escape  of 
fecal  contents  into  the  peritoneal  cavity,  or  from  propagation  of  inflam- 
mation along  the  coats  of  the  bowel  above  the  constriction.  There 
may  be  a  volvulus  of  the  intestine  leading  up  to  the  hernial  ring, 
within  the  abdominal  cavity. 


Fig.  852. — Specimen  of  gangrenous  small  intestine  resected  in  a  case  of  strangulated 
femoral  hernia.  Age  seventy-one  years;  hernia  strangulated  for  two  weeks  before 
operation.  Fecal  abscess  in  sac,  bowel  ruptured  just  above  proximal  constriction. 
Death  twelve  hours  after  operation  (spinal  anesthesia).    Episcopal  Hospital. 

If  omentum  is  strangulated  there  is  not  much  serum  effused  in  the 
sac.  The  omental  veins  are  found  distended,  dark  blue  or  black, 
and  perhaps  thrombosed.  The  omental  fat  becomes  pinkish  red  at 
first,  feels  denser  than  normal,  and  does  not  bleed  readily  if  incised; 
later  it  becomes  grayish  white  and  perhaps  necrotic. 

Symptoms  of  Strangulated  Hernia. — In  almost  every  case  the  patient 
has  had  a  hernia  for  some  time  before  it  becomes  strangulated.  Usually 
following  a  muscular  strain  (perhaps  merely  a  mis-step^  exuberant 
laughter,  etc.)  a  sudden  pain  is  felt  at  the  site  of  the  hernia.  If  the 
hernia  was  not  down  at  the  time  of  the  accident,  it  slips  out  suddenly, 
even  escaping  from  under  a  truss  if  one  was  worn.  If  the  hernia  was 
down  already  at  the  time  of  the  accident,  whether  irreducible  or  not, 
it  feels  to  the  patient  as  if  it  had  increased  in  size  from  the  protrusion 


816  HERNIA 

of  additional  bowel  or  omentum.  If  the  pain  is  very  severe  the  patient 
may  fall  to  the  ground  in  a  state  of  shock.  The  pain  is  followed  very 
soon  by  a  general  abdominal  pain  which  at  first  is  colicky,  becomes 
progressively  worse,  and  which  later  is  constant,  not  intermittent. 
//'  not  checked  by  opiates  this  pain  does  not  leave  the  patient  until  gan- 
grene  has  occurred  or  until  the  strangulation  is  relieved.  Spontaneous 
cessation  of  pain  therefore  is  a  bad  sign;  it  is  accompanied  by  a  false 
sense  of  security,  and  is  soon  followed  by  extreme  prostration,  and 
signs  of  impending  death  as  in  cases  of  intestinal  strangulation  from 
other  causes. 

If  the  hernia  is  an  enterocele,  the  usual  symptoms  of  intestinal 
obstruction  (p.  937)  develop  very  soon  after  the  occurrence  of  the 
strangulation.  The  initial  colicky  pain,  in  almost  all  cases  but  not 
always,  is  accompanied  or  followed  by  nausea  and  vomiting.  The 
vomiting,  which  at  first  is  the  result  of  nausea,  later  becomes  typically 
projectile  in  type,  due  not  to  nausea,  but  to  reversed  peristalsis. 
First  the  gastric  contents  are  vomited;  then  bile-stained  matter;  later 
the  contents  of  the  upper  intestine,  which  is  brownish  and  sour- 
smelling;  and  in  the  final  stages  true  fecal  or  stercoraceous  vomiting 
may  occur.  Coincident  with  these  symptoms  there  is  absolute  con- 
stipation, and  no  flatus  is  passed  by  the  rectum.  An  enema  may 
empty  the  rectum  of  what  was  already  there  or  in  the  sigmoid;  but 
after  the  lower  bowel  has  been  emptied,  no  further  movement  can  be 
obtained,  and  in  no  case  is  there  passage  of  flatus.  In  the  case  of  an 
epiplocele  the  symptoms  are  the  same  though  often  less  in  degree, 
there  being  seldom  absolute  constipation  or  complete  arrest  of  flatus. 

If  the  intestinal  obstruction  is  not  relieved,  peritonitis  will  develop, 
with  its  characteristic  symptoms  and  physical  signs  (p.  856).  Until 
this  event  occurs  the  temperature  is  not  elevated,  though  the  pulse 
slowly  but  steadily  increases  in  rapidity. 

Physical  examination  shows  a  tender,  painful,  and  tense  swelling 
at  the  site  of  the  hernia.  In  the  case  of  a  large  hernia  long  irreducible, 
these  signs  are  not  so  apparent,  but  usually  it  is  evident  that  the 
swelling  is  somewhat  more  tense  and  painful  than  before  the  onset  of 
the  symptoms  of  strangulation.  In  an  omental  hernia  the  swelling  is 
boggy,  rather  than  tense.  There  is  no  impulse  in  a  strangulated  hernia 
when  the  patient  coughs.  Palpation  of  the  abdomen  usually  reveals 
rigidity  of  the  abdominal  muscles  near  the  site  of  the  hernia;  it  is  a 
voluntary  rigidity,  not  like  that  which  results  from  peritonitis.  Auscul- 
tation of  the  abdomen  detects  sounds  of  borborygmi  characteristic 
of  peristalsis;  usually  these  peristaltic  noises  are  exaggerated,  and 
sometimes  they  may  be  traced  up  to  the  site  of  obstruction,  where 
they  are  arrested  with  a  distinct  click. 

Diagnosis  of  Strangulated  Hernia.— This  depends  on  recognizing,  in 
addition  to  the  symptoms  of  intestinal  obstruction,  the  existence  of 
a  hernia  with  the  signs  characteristic  of  strangulation.  If  the  latter 
condition  is  present,  it  is  not  necessary  to  wait  for  full  development 
of  symptoms  of  intestinal  obstruction  before  making  a  diagnosis.     I 


STRANGULATED  HERNIA  817 

have  several  times  found  a  gangrenous  patch  on  the  bowel  in  cases 
where  neither  nausea  nor  vomiting  had  been  present,  although  the 
strangulation  had  lasted  for  from  six  to  eight  hours.  In  very  fat 
patients  it  may  be  impossible  to  detect  with  certainty  a  very  small 
hernia.  All  the  usual  sites  of  hernia  should  be  carefully  examined, 
and  corresponding  parts  of  the  body  should  be  compared  most  dili- 
gently in  obscure  cases.  A  feeling  of  greater  resistance  over  one  hernial 
ring  than  at  the  corresponding  point  on  the  other  side  of  the  body  may 
be  the  only  physical  sign  discernible  in  a  case  of  partial  enterocele 
(Richter's  hernia);  but  such  small  hernise  may  become  gangrenous 
much  sooner  than  larger  herniae.  If  two  hernia,  both  irreducible,  are 
present,  it  may  be  difficult  to  decide  which  of  the  two  is  strangulated ; 
usually  the  physical  signs  (absence  of  impulse  on  coughing,  greater 
tension  and  tenderness  in  the  neck  of  the  strangulated  hernia)  will  be 
of  more  aid  in  such  cases  than  the  history  and  subjective  symptoms. 
An  irreducible  hernia  may  be  present  and  there  may  be  'peritonitis 
from  some  other  cause.  The  distinctions  between  intestinal  obstruc- 
tion and  peritonitis  cannot  be  too  often  insisted  upon;  they  are  detailed 
at  p.  860.  In  strangulated  hernia  peritonitis  is  a  late  symptom,  all 
the  early  signs  indicating  intestinal  obstruction.  There  may  be  an 
irreducible  hernia  and  yet  there  may  be  some  other  cause  for  intestinal 
obstruction:  here  again  physical  examination  will  show  an  impulse  on 
coughing  unless  the  hernia  is  strangulated;  while  a  careful  history  of 
the  case  may  throw  much  light  on  the  diagnosis  as  it  may  indicate 
previous  attacks  of  peritonitis,  leaving  crippling  bands  or  adhesions 
as  the  true  cause  of  the  symptoms.  If  no  conclusion  can  be  reached 
after  careful  study,  the  surgeon  should  expose  the  hernia  before 
proceeding  to  exploratory  laparotomy.  The  vomiting  of  pregnancy  may 
be  confusing,  if  an  irreducible  hernia  is  present;  but  the  negative 
physical  examination  of  the  hernia,  and  the  fact  that  there  is  no 
evidence  of  intestinal  obstruction,  should  be  sufficient  evidence  of  the 
true  condition.  In  some  cases  of  inguinal  hernia,  confusion  is  caused 
by  the  presence  of  an  inflamed  lymph  node  in  the  groin,  and  in  infants 
by  an  inflamed  hydrocele  of  the  cord.  When,  as  often  in  these  cases, 
physical  examination  is  unsatisfactory,  and  the  history  is  unknown 
or  negative,  a  differentiation  may  be  impossible.  An  undescended 
testicle  need  not  be  mistaken  for  a  strangulated  hernia  if  the  surgeon 
is  cautious  enough  to  examine  the  scrotum  before  reaching  a  diagnosis. 
Treatment  of  Strangulated  Hernia. — The  object  of  treatment  is  to 
relieve  the  strangulation.  This  may  be  accomplished  (1)  by  pushing 
the  strangulated  bowel  or  omentum  back  into  the  abdominal  cavity 
by  means  of  Taxis;  or  (2)  by  operation — dividing  the  constriction, 
inspecting  the  bowel,  and  treating  it  appropriately  before  restoring 
it  to  the  abdomen.  In  most  cases  this  operation  may  be  completed 
by  repair  of  the  abdominal  wall  so  as  to  prevent  recurrence  of  the 
hernia.  The  physician  never  should  leave  his  patient  until  the  stran- 
gulation has  been  relieved,  or  until  he  has  made  arrangements  for 
immediate  surgical  treatment. 


818  HERNIA 

Taxis.— This  is  a  term  derived  from  the  Greek,  and  implying 
arrangement  or  adjustment.  It  is  used  in  surgery  in  a  technical  sense 
to  describe  various  manipulations  by  which  the  surgeon  seeks  to  secure 
reduction  of  a  hernia.  The  patient  should  be  placed  on  a  bed,  with 
his  shoulders  and  pelvis  raised,  so  as  to  relax  the  abdominal  muscles. 
The  surgeon  then  surrounds  the  hernial  orifice  with  the  thumb  and 
fingers  of  his  left  hand,  while  with  the  right  he  endeavors  by  very 
gentle  but  persistent  compression  to  empty  the  herniated  bowel  of 
some  of  its  gaseous  and  fluid  contents.  When  this  has  been  accom- 
plished, he  employs  his  right  hand  in  the  most  gentle  and  patient 
kneading  movements,  in  the  attempt  to  make  the  bowel  recede  into 
the  abdomen.  The  direction  of  pressure  must  correspond  to  that  by 
which  the  bowel  came  down.  Success  is  manifested  by  the  bowel 
slipping  back  into  the  abdomen  with  an  audible  gurgle  and  a  charac- 
teristic flop.  If  these  signs  are  absent,  even  though  the  hernia  appears 
to  have  been  reduced,  it  is  most  probable  that  this  is  not  really  the 
case,  but  that  reduction  in  mass  has  occurred.  This  term  implies 
that  the  contents  of  the  sac  have  been  pushed  upward  until  they  lie 
on  the  inner  aspect  of  the  abdominal  wall,  but  have  carried  before 
them  the  neck  of  the  sac,  which  is  the  seat  of  constriction;  and  that 
the  hernia,  still  strangulated,  rests  between  the  abdominal  wall  and 
parietal  peritoneum.  If  the  symptoms  of  strangulation  persist, 
operation  should  be  done  immediately. 

Contraindications  to  the  Taxis. — (1)  Taxis  never  should  be  employed 
if  anyone  else  already  has  attempted  it;  because  there  is  no  telling  how 
much  damage  may  have  been  done  to  the  gut,  and  in  its  present  state 
even  the  very  gentlest  manipulation  may  rupture  it  or  cause  other 
disastrous  consequences.  (2)  Taxis  never  should  be  employed  in  very 
acute  cases;  it  is  suitable  only  to  such  as  begin  with  symptoms  of 
incarceration  or  obstruction  of  the  hernia.  (3)  Taxis  never  should  be 
employed  while  the  patient  is  anesthetized,  as  there  is  too  much  risk 
of  using  unjustifiable  force.  (4)  Taxis  never  should  be  persisted  in 
for  more  than  fifteen  minutes. 

Operation. — The  operation  for  strangulated  hernia  is  one  which 
any  medical  man  may  be  called  on  to  perform  in  emergency.  It  is 
not  nearly  so  difficult  as  is  the  taxis,  and  is  incomparably  more  efficient 
in  securing  the  end  in  view — that  of  relief  of  strangulation.  If  opera- 
tion were  resorted  to  in  every  case  within  the  first  twelve  hours,  and 
with  modern  aseptic  methods,  the  mortality  of  strangulated  hernia 
would  be  only  from  3  to  5  per  cent.,  or  less  than  half  that  of  typhoid 
fever;  instead  of  as  high  as  that  of  pneumonia,  or  fracture  of  the  base 
of  the  skull,  as  it  is  now,  when  in  many  cases  the  obstinacy  of  the 
patient  or  still  worse  the  ignorance  of  the  family  physician  post- 
pones operation  until  gangrene  and  peritonitis  have  developed.  The 
mortality  when  operation  is  employed  under  such  circumstances 
varies  from  10  to  50  per  cent.,  according  to  the  constitutional  resist- 
ance of  the  patient.  If  no  operation  is  done,  spontaneous  cure  by 
sloughing  and  formation  of  a  fecal  fistula  may  result  in  as  many  as 
2  per  cent,  of  cases,  while  98  per  cent,  will  terminate  in  death. 


STRANGULATED  HERNIA  819 

The  operation,  which  is  known  as  herniotomy  or  kelotomy,  consists 
essentially  in  making  an  incision  through  the  overlying  structures 
until  the  neck  of  the  sac  is  exposed;  then  the  sac  is  opened,  and  the 
constriction  causing  strangulation  is  divided.  For  this  deep  incision 
many  surgeons  still  use  Cooper's  herniotome  (Fig.  853)  which  has  the 
advantages  of  a  blunt  point  which  can  be  slipped  under  the  constriction 
and  a  short  cutting  edge.  The  contents  of  the  sac  are  then  replaced 
within  the  abdomen  if  they  are  in  good  condition,  and  the  wound  is 
repaired  as  in  an  operation  undertaken  for  the  "radical  cure"  of 
hernia.  If  the  contents  of  the  sac  are  not  in  good  condition  they  are 
treated  as  described  below  (see  Treatment  of  Complications). 


Fig.  853. — Cooper's  herniotome. 

In  former  times,  before  the  days  of  aseptic  surgery,  there  was  great 
danger  of  peritonitis  developing  after  such  an  operation,  and  much 
more  stress  was  laid  upon  the  employment  of  taxis,  and  even  in 
operating  many  surgeons  followed  the  method  of  Petit  (1760),  who 
divided  extra-saccular  constrictions  and  then  reduced  the  hernia 
without  opening  the  sac.  But  for  the  last  thirty  years  at  least,  the 
taxis  has  been  falling  increasingly  into  disfavor;  and  especially  since 
the  development  of  methods  of  inducing  local  anesthesia,  and  spinal 
analgesia,  have  surgeons  been  more  ready  to  resort  to  operation. 
And  I  am  convinced  that  it  should  be  clearly  understood  that  no 
patients  however  moribund  in  appearance  (unless  in  articulo  mortis) 
should  be  refused  the  hope  of  recovery  which  operation  always  affords. 
If  the  patient  is  too  ill  to  endure  a  general  anesthetic,  and  if  no  facili- 
ties exist  for  administering  local  or  spinal  anesthesia,  there  is  no  reason 
in  the  world  why  the  operation  should  not  be  done  without  any 
anesthetic  whatever.  Our  surgical  ancestors  operated  thus  for  many 
generations,  and  in  not  an  insignificant  proportion  of  cases  recovery 
followed. 

Treatment  of  Complications. — As  the  surgeon  cuts  through  the 
overlying  tissues  he  may  find  that  they  are  edematous.  This  may  be 
the  result  of  trauma  inflicted  during  attempts  at  taxis,  or  rarely  may 
be  due  to  inflammation  spreading  from  a  fecal  abscess  in  the  sac.  The 
sac  usually  is  recognized  by  its  transulucent  and  bluish  appearance. 
Usually  it  is  impossible,  and  never  is  it  requisite  for  the  surgeon  to 
recognize  the  various  layers  of  tissue  overlying  the  sac.  Each  of  the 
deeper  layers  as  it  appears  should  be  cut  through  cautiously,  as  one 
opens  the  peritoneum,  after  raising  it  in  forceps  from  the  underlying 
structures.  In  this  way  there  is  very  little  danger  of  injury  to  the 
contents  of  the  hernial  sac.  In  most  cases  there  is  some  fluid  in  the 
sac;  if  it  is  clear  and  limpid,  it  is  not  likely  that  the  condition  of  the 
bowel  is  very  bad.  When  the  sac  is  opened  and  the  constriction 
relieved,  more  of  the  bowel  should  be  drawn  out  of  the  abdomen,  and 


820  HERNIA 

its  condition  should  be  carefully  observed.  (In  serious  cases  the  anes- 
thetic, if  given  by  inhalation,  may  be  suspended  at  this  point  in 
the  operation.)  If  the  bowel  was  merely  nipped  in  the  hernial  orifice, 
and  has  fallen  back  into  the  abdomen  as  soon  as  the  constriction  is 
relieved,  the  surgeon  never  should  neglect  to  draw  it  out  again  into 
the  wound  to  ascertain  its  condition.  The  next  step  is  the  application 
to  the  bowel  of  hot  (115°  F.)  sterile  water  or  saline  solution.  The 
hot  fluid  should  not  be  poured  over  the  bowel  with  any  force, 
but  should  be  allowed  to  flow  gently  over  the  bowel  so  as  to  avoid  the 
trauma  even  of  a  current  of  water.  Nor  should  the  bowel  be  sub- 
jected to  massage  or  to  irritation  by  gauze  sponges.  The  bowel  should 
be  examined  for  its  luster,  its  color,  and  its  elasticiiy.  Though  the 
color  when  first  exposed  may  be  bright  red,  bluish,  dark  blue,  purple, 
or  even  black,  it  may  return  to  normal  after  relief  of  the  strangulation 
and  application  of  hot  solutions  for  a  varying  time  up  to  half  an  hour. 
If  the  gut  is  entirely  gangrenous  when  first  seen,  of  course  it  is  hope- 
less to  expect  its  recuperation;  but  recovery  may  occur  from  any 
stage  short  of  gangrene;  and  a  patch  of  seeming  gangrene  which  at 
first  appears  so  large  as  to  demand  resection,  may  be  so  much  dimin- 
ished in  size  by  hot  applications  as  to  permit  of  retention  of  the  bowel 
after  inversion  of  the  worst  portions.  If  the  luster  of  the  peritoneal 
coat  is  preserved,  as  a  rule  the  color  will  return  to  the  normal  and  the 
bowel  will  survive.  If  the  mesenteric  vessels  cannot  be  felt  pulsating 
the  bowel  will  not  survive.  If  the  bowel  fills  out  with  its  contained 
air  and  retains  its  normal  cylindrical  form,  it  is  more  apt  to  be  healthy 
than  if  it  has  lost  its  resiliency  and  retains  any  indentation  or  crease 
accidentally  produced  during  manipulation.  Careful  inspection  should 
be  made  also  of  the  circular  constrictions  on  the  bowel  at  the  points  of 
strangulation,  if  such  constrictions  exist.  There  may  be  a  threatening 
perforation  here,  while  the  intervening  portion  of  bowel  which  was  not 
directly  compressed,  but  had  its  circulation  impaired  only  by  pressure 
on  its  mesentery,  may  be  fairly  normal. 

If  the  bowel  returns  to  its  normal  condition,  it  should  be  replaced, 
and  the  wound  should  be  closed.  If  a  suspected  spot  remains,  it  often 
is  possible  to  cover  it  in  by  inverting  it  and  suturing  neighboring 
healthy  portions  of  bowel  over  it,  as  indicated  in  the  accompanying 
diagrams.  Even  though  the  entire  lumen  of  the  gut  appears  to  be 
obstructed  by  the  amount  of  its  wall  inverted,  recovery  without  any 
untoward  symptom  may  occur  (Fig.  854).  The  sero-serous  suture 
is  used,  as  in  other  intestinal  operations  (p.  880).  If  the  circular 
constriction  at  the  point  of  strangulation  has  been  very  tight,  it  will 
have  crushed  all  the  coats  of  the  bowel  except  the  peritoneum  at  this 
point,  just  as  if  a  compression  forceps  had  been  applied  to  the  gut 
previous  to  the  application  of  a  ligature.  In  such  circumstances  the 
ring  of  constriction  sometimes  may  be  covered  in  by  producing  a 
partial  intussusception  of  the  bowel  (Fig.  855). 

Only  if  there  is  actual  gangrene  is  resection  desirable;  and  even  in 
such  cases,  if  the  patient's  condition  is  very  bad,  or  if  the  operator  is 


STRANGULATED  HERNIA 


821 


inexperienced,  it  will  be  quite  sufficient  to  leave  the  gangrenous  coil 
of  intestine  lying  in  the  sac,  after  relieving  the  constriction,  and 
packing  sterile  gauze  around  the  bowel,  which  should  then  be  opened 
and  drained.  If  the  proximal  (afferent)  bowel  is  very  much  distended, 
or  if  the  strangulation  has  existed  a  long  time,  it  always  is  well  to 
evacuate  the  contents  of  the  proximal  loop  (which  in  such  cases  are 
regarded  as  highly  toxic),  instead  of  allowing  these  contents  to  pass 
on  down  through  the  intestinal  canal,  whence  absorption  may  occur, 
causing  increased  toxemia. 


Fig.  854. — Gangrenous  spot  on  bowel 
(a),  inverted  into  lumen  by  sutures  (6). 
From  a  patient  in  the  Episcopal  Hospital. 
Recovery. 


Fig.  855. — Gangrenous  area  involving 
nearly  whole  circumference  of  bowel  (a), 
successfully  treated  by  producing  a  partial 
intussusception  (6).     Episcopal  Hospital. 


Where  resection  of  the  bowel  is  done  the  surgeon  may  terminate 
the  operation  either  by  establishing  a  false  anus  in  the  wound  (p.  969), 
or  by  completing  an  intestinal  anastomosis.  The  former  should  be 
selected  in  all  cases  where  a  prolongation  of  the  operation  is  not 
desirable,  unless  the  site  of  resection  is  very  high  in  the  intestinal 
canal.  When  an  anastomosis  is  done  it  may  be  either  an  end-to-end 
anastomosis  or  a  lateral  anastomosis  (p.  884).  In  these  cases  no  fur- 
ther prolongation  of  the  operation  is  desirable,  so  no  attempt  at  a 
"radical  cure"  of  the  hernia  should  be  made;  it  is  sufficient  to  close 
the  wound,  usually  with  drainage,  in  the  simplest  and  most  expe- 
ditious manner. 

The  treatment  of  omentum  found  in  the  sac  demands  a  few  words  of 
explanation.  If  there  is  no  serious  change  in  this  structure,  it  may  be 
replaced;  but  if  there  is  any  doubt  about  its  condition,  it  should  be 


822 


HERNIA 


excised,  after  tying  it  off  where  normal  by  a  series  of  interlocking 
ligatures,  below  which  it  is  cut  away,  leaving  a  sufficient  stump  to 
ensure  that  the  ligatures  will  not  slip.  Each  ligature  should  include 
no  more  than  a  pencil's  thickness  of  the  omentum,  and  the  omentum 
should  be  excised  before  the  ligatures  are  cut  short,  so  that  the  sur- 
geon may  use  them  to  hold  the  omental  stump  in  the  wound  for  careful 
inspection,  to  make  sure  that  hemorrhage  is  controlled.  The  omental 
bloodvessels  have  no  muscular  coats,  and  do  not  retract  or  contract 
and  allow  spontaneous  cessation  of  bleeding.  Not  unfrequently  the 
omentum  protrudes  in  a  loop,  into  the  hernial  sac  (Fig.  850),  and  unless 


Fig.  856. — Loop  of  omentum  protruding  into  hernial  sac,  but  having  its  free  end 
within  the  abdominal  cavity.  Complications  might  ensue  if  this  free  end  was  not 
drawn  out  before  ligating  and  cutting  off  the  omentum. 

care  is  taken  to  pull  the  end  of  the  loop  out  of  the  abdomen  before  its 
base  is  ligated  there  will  be  danger  of  its  necrosing  and  causing  peri- 
tonitis or  obstruction  later.  The  omentum  is  so  seldom  normal  when 
it  has  been  long  in  a  hernial  sac,  even  if  not  strangulated,  that  I  believe 
it  is  much  better  to  excise  it  under  all  circumstances,  unless  the  con- 
dition of  the  patient  is  such  as  to  render  any  prolongation  of  the 
operation  unjustifiable.  If  it  is  restored  to  the  abdomen  it  is  quite 
likely  to  cause  subsequent  trouble  either  by  adhesions  or  by  favoring 
recurrence  of  the  hernia  (Lucas-Championniere) . 

The  after-treatment  is  the  same  as  after  other  operations  for  intestinal 
obstruction.  If  the  wound  has  not  been  securely  repaired,  the  patient 
should  be  operated  on  after  complete  recovery,  to  obtain  a  cure;  or  a 
truss  should  be  worn  to  prevent  reappearance  of  the  hernia. 


SPECIAL  HERNLffi. 

Classification. — There  are  only  three  forms  of  hernia  of  frequent 
occurrence;  all  the  others  are  rare.  The  most  frequent  form  is  the 
inguinal,  which  occurs  in  about  73  per  cent,  of  cases;  then  comes  the 
femoral,  in  about  18  per  cent,  of  cases;  and  lastly  the  umbilical,  which 
occurs  in  about  8.5  per  cent,  of  cases.     This  leaves  about  1  per  cent. 


VENTRAL  HERNIA  823 

for  the  rarer  forms  (lumbar,  obturator,  etc.).  In  this  reckoning, 
however,  incisional  hernia  is  not  included.  To  afford  a  perspectus  of 
the  subject  to  the  student,  there  is  no  more  serviceable  classification 
of  hernia  than  the  following: 

Hernle  of  the  Epigastric  Region. 

1.  Diaphragmatic. 

2.  Epigastric. 

Hernia  of  the  Mesogastric  Region. 

1.  Ventral. 

2.  Incisional— These  may  occur  also  in  other  regions. 

3.  Umbilical. 

4.  Lumbar. 

Hernle  of  the  Hypogastric  Region. 

1.  Inguinal. 

1.  Indirect  (or  Oblique). 

2.  Direct. 

2.  Femoral  or  Crural. 

3.  Pelvic. 

1.  Anterior — obturator. 

f  (1)  Perineal. 

2.  Inferior       (2)  Pudendal. 

(3)  Vaginal. 

3-PoSteriOT{SGSa1r- 

These  various  forms  will  now  be  discussed  in  turn.  Diaphragmatic 
Hernia  has  already  been  considered  (p.  802).  Internal  Hernia  is 
discussed  in  Chapter  XXII. 

Epigastric  Hernia. — By  this  term  is  understood  orie  or  more  small 
protrusions,  usually  of  omentum  only,  occurring  in  or  near  the  median 
line  of  the  abdomen  (linea  alba)  between  ensiform  process  and  um- 
bilicus. It  is  a  rare  condition,  first  well  studied  by  Terrier  in  1886. 
A  much  more  frequent  abnormality,  and  one  which  often  is  mistaken 
for  a  true  hernia,  is  the  protrusion  of  small  portions  of  the  preperi- 
toneal fat  through  apertures  between  the  transverse  fibers  of  the 
sheaths  of  the  recti  muscles  which  go  to  form  the  linea  alba.  Accord- 
ing to  Tillaux  (1894)  it  is  more  frequent  in  men.  The  patient  com- 
plains of  pain,  and  on  examination  a  small  mass  can  be  felt  the  size  of 
a  marble  or  thereabouts,  and  generally  irreducible.  It  simulates  an 
epiplocele. 

Treatment. — If  a  fatty  tumor  is  found  it  may  be  excised,  after 
exposing  and  ligating  its  pedicle.  If  the  linea  alba  is  carefully  sutured 
there  is  not  apt  to  be  a  recurrence.  A  true  hernia  should  be  treated  by 
excision  of  the  sac,  and  suture  of  parietal  peritoneum  and  linea  alba. 

Ventral  Hernia. — This  hernia  may  occur  in  any  part  of  the  abdomi- 
nal wall,  but  does  not  protrude  through  one  of  the  usual  apertures 
such  as  the  umbilicus,  the  inguinal  or  femoral  canals,  etc.  It  is  a 
very  rare  form  of  hernia,  though  by  many  surgeons  it  is  not  distin- 
guished from  incisional  hernia  (see  below).  The  usual  cause  is  injury 
resulting  in  partial  rupture  of  the  abdominal  muscles,  from  a  direct 
blow  or  merely  by  muscular  strain.    In  some  cases  no  distinct  history 


824 


HERNIA 


of  injury  can  be  obtained,  the  abdominal  wall  seeming  to  have  yielded 
spontaneously  at  the  site  where  the  hernia  appears  (Fig.  857).  No 
true  sac  exists,  the  parietal  peritoneum  merely  bulging  a  little  when 
the  patient  strains. 

Under  the  heading  of  ventral  hernia  may  be  included  also  protru- 
sion due  to  diastasis  of  the  recti  muscles  in  the  mid-line.  A  slight 
degree  of  diastasis  is  normal  above  the  umbilicus,  but  pathological 
diastasis  usually  is  seen  in  the  hypogastric  region,  and  occurs  in 
women  who  have  borne  many  children  and  who  are  emaciated.  A 
similar  condition  is  frequently  seen  in  infants  and  young  children,  as 
a  congenital  deformity. 


Fig.  857. — Ventral  hernia  through  right  oblique  muscles. 
Episcopal  Hospital. 


(Dr.  Neilson's  case.) 


Symptoms. — The  symptoms  of  ventral  hernia  are  a  feeling  of  weak- 
ness at  the  site  of  the  protrusion,  and  dragging  sensations  within  the 
abdomen.  The  diagnosis  is  not  difficult,  if  the  possible  existence  of 
the  condition  is  remembered. 

Treatment.— Usually  symptomatic  relief  is  secured  by  wearing  a 
firm  abdominal  belt.  In  children  with  diastasis  of  the  recti  the  use 
of  adhesive  plaster  strapping  as  advised  in  cases  of  umbilical  hernia 
usually  effects  a  cure.  Even  in  adults  the  hernia  is  not  liable  to  com- 
plications, but  if  desired  the  patient  can  secure  permanent  relief  by 
an  operation  as  for  incisional  hernia. 

Incisional  Hernia. — This  is  much  more  frequent  than  a  true  ventral 
hernia,  and  receives  its  name  from  its  development  in  the  cicatrix  of 
an  operative  incision.  One  cannot  too  much  insist  upon  the  impor- 
tance of  placing  the  incision  so  as  to  do  as  little  damage  as  possible  to 
the  structures  of  the  abdominal  wall  (see  p.  870).  Incisional  hernia 
was  much  more  frequent  formerly  when  less  care  was  taken  in  the 
repair  of  abdominal  wounds.  An  incisional  hernia  is  very  rare  in  a 
clean  wound  which  is  closed  completely  by  tier  suture.  If  the  wound 
is  drained,  a  hernia  is  much  more  apt  to  develop. 


INCISIONAL  HERNIA 


825 


This  form  of  hernia  may  be  of  any  size,  and  if  large  may  cause 
very  great  disability.  Usually  there  is  no  true  peritoneal  sac,  but  the 
abdominal  viscera  lie  in  direct  contact  with  fascia  or  skin,  and  almost 
always  are  closely  adherent  to  their  coverings.  Owing  to  this  fact 
there  is  no  chance  for  spontaneous  cure  even  if  the  hernia  is  kept 
reduced  by  suitable  appliances.  As  the  abdominal  opening  is  rela- 
tively large,  strangulation  or  other  lesser  complication  is  rare;  though 
incarceration  may  occur  if  the  aperture  is  small. 

The  'symptoms  are  the  same  as  in  ventral  hernia. 


Fig.  858. — Incisional  hernia,  in  scar 
of  operation  for  appendicitis  seven 
years  ago  (incision  in  right  semilunar 
line).     Episcopal  Hospital. 


Fig.  859. — Incisional  hernia,  in  scar  of 
operation  for  typhoid  perforation  of  intes- 
tine nine  years  ago  (right  rectus  incision). 
Two  years  ago  a  right  inguinal  hernia  also 
developed.  Age  thirty-six  years.  (Dr. 
Harte's  case.)     Episcopal  Hospital. 


Treatment. — If  the  patient  is  healthy,  operation  should  be  done. 
If  this  is  contraindicated,  an  abdominal  belt,  as  in  cases  of  pendulous 
abdomen  (Fig.  963),  may  relieve  the  worst  symptoms.  When  operation 
is  done  it  should  be  remembered  that  the  cicatrix  is  usually  very  thin 
and  the  hernial  contents  adherent.  The  surgeon,  therefore,  begins  by 
an  incision  at  the  periphery  of  the  hernia,  and  opens  the  abdomen  not 
directly  through  the  old  cicatrix,  but  through  healthy  tissues  above 
or  below  or  to  one  side  of  the  hernia.  Here  there  will  be  no  adhe- 
sions to  the  parietal  peritoneum.  The  hernial  contents  are  then 
cautiously  dissected  free  from  the  overlying  abdominal  wall,  the  cica- 
tricial tissue  is  excised,  and  the  herniated  structures  reduced.  In 
cases  of  very  large  hernia  with  many  adhesions  between  the  prolapsed 
intestines  and  omentum  it  is  not  desirable  to  separate  these  more 
than  is  required  to  free  the  different  layers  of  the  abdominal  wall. 
Redundant  or  diseased  omentum  should  be  excised.  The  various 
layers  of  the  abdominal  wall,  especially  the  aponeuroses,  should  be 
dissected  free,  exposing  enough  of  each  for  accurate  suture,  and  if 
possible  for  overlapping.  Then  the  wound  should  be  repaired  as  a 
recent  abdominal  incision  (p.  873).    The  most  important  layer  of  the 


82G  HERNIA 

abdominal  wall  to  suture  accurately  is  the  anterior  sheath  of  the  rectus 
or  the  aponeurosis  of  the  external  oblique.  Ilemostasis  should  be 
absolute,  and  the  wound  should  not  be  drained.  The  patient  should 
remain  in  bed  for  at  least  three  weeks,  and  if  the  hernia  was  large 
should  wear  an  abdominal  belt  and  avoid  straining  efforts  for  a  year 
after  operation.  Bartlett  (1903)  and  other  surgeons  have  implanted 
silver  wire  filigree  in  these  wounds,  with  a  view  of  rendering  them 
stronger.  Recent  experience  has  shown  that  free  flaps  of  fascia  lata 
can  be  transplanted  to  supply  a  defect. 

Umbilical  Hernia. — This  is  a  frequent  affection,  especially  in 
infants  and  stout  adults  past  middle  life.  Three  forms  are  to  be 
distinguished,  the  Congenital,  the  Infantile,  and  the  Adult. 

Congenital  Umbilical  Hernia  is  rare,  occurring  once  in  five  or  six 
thousand  births.  It  is  classed  as  embryonic  and  fetal.  The  former  is 
due  to  failure  of  development  of  the  abdominal  wall,  and  the  hernia, 
or  rather  eventration,  may  be  very  extensive,  containing  beside 
intestine  also  stomach,  liver,  heart,  etc.  The  fetal  variety  develops 
after  the  third  month  of  intra-uterine  life,  and  the  sac  is  lined  by 
peritoneum  and  seldom  is  very  large.  Infants  with  large  embryonic 
hernia  usually  are  stillborn,  or  die  so  soon  after  birth  as  to  offer  little 
chance  for  repair  of  the  defect  by  surgical  means.  The  smaller  fetal 
hernia  usually  is  covered  only  by  a  translucent  membrane  through 
which  the  herniated  viscera  can  be  seen.  Other  malformations,  espe- 
cially of  the  bladder  or  rectum,  may  be  present. 

Treatment. — The  hernia  should  be  repaired  by  operation  so  soon  as 
possible.  The  general  mortality  is  about  30  per  cent.,  but  is  less  after 
operation  done  on  the  first  day  of  life  than  later. 

Umbilical  Hernia  in  Infants  and  Children  is  very  frequent.  It  develops 
at  any  time  after  complete  cicatrization  of  the  navel,  and  seldom 
appears  first  after  the  close  of  the  second  year  of  life.  The  hernia 
seldom  is  very  large,  is  covered  by  normal  skin,  and  usually  appears 
not  directly  under  the  umbilical  cicatrix,  but  slightly  above  and  to 
one  side.  Pressure  by  a  finger  reduces  the  hernia  easily,  and  when 
the  child  cries  or  strains  it  becomes  larger  and  more  tense  (Fig.  860) . 

Treatment. — If  the  hernia  is  small  and  the  child  is  young,  there 
is  some  chance  of  cure  without  operation.  With  the  child  lying  down, 
one  end  of  a  strip  of  adhesive  plaster,  about  two  inches  wide  is  fixed 
in  one  lumbar  region;  then  the  surgeon  draws  the  opposite  side  of  the 
belly  forward,  so  as  to  form  a  longitudinal  fold  in  the  region  of  the 
linea  alba.  The  adhesive  plaster  is  then  drawn  across  the  relaxed 
belly  and  is  tightly  applied  to  the  loin  on  the  other  side.  It  is  well 
to  reinforce  this  first  strip  by  one  or  two  others.  It  is  better  not  to 
place  a  button,  or  a  coin,  or  pad,  or  anything  else  over  the  hernia,  as 
these  tend  to  keep  open  the  hernial  ring.  The  adhesive  plaster  should 
be  renewed  about  once  a  week,  or  as  often  as  it  comes  loose.  Care 
must  be  taken  to  keep  the  hernia  reduced  by  the  finger  while  the 
plaster  is  being  changed.  Attention  is  necessary  to  prevent  excoria- 
tions of  the  skin.    If  the  plaster  is  applied  too  tightly  it  may  encourage 


UMBILICAL  HERNIA 


827 


the  development  of  inguinal  hernia.  If  this  method  of  strapping  an 
umbilical  hernia  is  faithfully  continued  for  a  year,  a  cure  will  result 
in  a  large  number  of  cases  if  the  hernia  is  small  and  of  short  duration. 
If  no  improvement  is  apparent  within  four  or  six  months,  operation 
probably  will  be  necessary. 

Operation  for  infantile  umbilical  hernia  is  best  done  after  the  child 
is  two  years  old.  This  will  allow  a  fair  trial  of  conservative  treatment. 
I  think  it  is  well  in  children,  especially  in  boys  who  are  exposed  more 
than  girls  to  ridicule  for  any  abnormality,  to  do  an  operation  which 
permits  preservation  of  the  navel,  as  advised  by  Stone.  I  make  a  semi- 
lunar incision,  below  the  umbilicus,  in  the  direction  of  the  folds  of  the 
skin,  and  turn  this  skin  flap  upward,  exposing  the  hernial  ring,  which 
is  treated  as  in  adults;  when  the  skin  flap  is  replaced,  the  patient's 
aspect  is  quite  normal  (Fig.  861). 


Fig.  860. — Umbilical  hernia  in  a 
rachitic  negro  boy.  Children's 
Hospital. 


Fig.  861. — -Result  of  operation  for  umbilica 
hernia  with  preservation  of  the  navel.  Children's 
Hospital. 


Umbilical  Hernia  in  Adults. — This  may  be  a  sequel  or  recurrence  of 
the  infantile  form,  or  may  develop  first  in  adult  life.  It  is  more  fre- 
quent in  women,  being  predisposed  to  by  repeated  pregnancies.  As 
in  infants  and  children,  the  protrusion  usually  occurs  slightly  above 
the  umbilical  cicatrix.  Omentum  is  almost  always  present  in  the 
sac,  and  generally  becomes  adherent,  rendering  the  hernia  irreducible 


828 


HERNIA 


at  least  in  part.  When  the  hernia  is  allowed  to  grow  large,  it  becomes 
pendulous  (Fig.  862),  and  usually  contains  transverse  colon  and  often 
small  intestine  also.  Incarceration  is  frequent,  and  strangulation  not 
unusual.  Strangulation  often  is  intra-saccular,  a  coil  of  gut  being 
caught  in  the  matted  and  hypertrophied  omentum.  The  coverings 
of  the  hernia  are  skin,  subcutaneous  fat,  a  thin  layer  of  fascia,  pre- 
peritoneal fat,  and  peritoneum;  the  latter  forms  the  sac,  which  is 
acquired,  not  congenital.  The  pressure  of  the  hernia  causes  atrophy 
of  the  tissues  overlying  it,  and  the  contents  of  the  sac  usually  lie  very 
close  to  the  skin,  at  least  over  the  fundus  of  the  sac.  In  many  cases 
there  is  also  considerable  diastasis  of  the  recti  muscles,  both  above 
and  below  the  ring. 


Fig.  862. — Umbilical  hernia  in  adult.     Age  fifty-two  years;  duration  two  years. 
Episcopal  Hospital. 

Treatment. — The  best  treatment  is  by  operation.  Before  this  is 
attempted,  however,  it  is  very  important  to  secure  reduction  of  as 
much  of  the  hernia  as  is  possible,  by  the  means  described  at  p.  812. 

A  transverse  incision  is  made,  outlining  an  ellipse  of  the  redundant 
skin,  including  the  umbilicus.  This  incision  should  extend  from  one 
semilunar  line  to  the  other,  and  in  very  fat  patients  may  have  to  be 
even  longer.  This  incision  exposes  the  anterior  sheaths  of  the  recti 
muscles  on  all  sides  of  the  hernial  ring,  and  at  some  distance  from  it. 
The  fat  is  then  dissected  off  the  aponeurosis  up  to  the  borders  of  the 
ring,  and  at  this  point  the  sac  is  cautiously  opened,  with  the  usual 
precautions  against  wounding  its  contents.  This  is  very  hard  to 
avoid,  if  an  attempt  is  made  to  open  the  sac  at  its  fundus.  The  sac 
is  then  cut  away  with  scissors  at  the  margins  of  the  hernial  ring,  on 
the  finger  as  a  guide,  and  the  parietal  peritoneum  as  cut  is  caught  in 
clamps  to  prevent  it  from  retracting  out  of  sight.  The  reducible  con- 
tents of  the  sac  are  then  replaced  in  the  abdomen.  Usually  a  good  deal 
of  omentum  has  to  be  excised;  this  should  be  done  with  the  precau- 
tions recommended  at  p.  821.  The  skin  containing  the  umbilicus, 
circumscribed  by  the  original  incision,  is  removed  in  one  piece  with  the 


UMBILICAL  HERNIA 


829 


hernial  sac  (Omphalectomy).  When  all  the  hernial  contents  have 
been  replaced,  a  gauze  pack  is  inserted  to  plug  the  opening  and  keep 
them  from  protruding  again.  The  next  step  is  closure  of  the  hernial 
ring:  a  transverse  incision  is  made  outward  for  about  3  cm.  from  the 
hernial  ring  through  the  anterior  sheath  of  each  rectus  muscle.  Usually 
there  is  diastasis  of  these  muscles,  and  for  a  distance  of  2  cm.  or 
more  on  each  side  of  the  mid-line  the  anterior  and  posterior  sheaths 
of  the  recti  may  be  in  contact.  The  anterior  sheaths  alone  are  to  be 
incised,  and  are  dissected  upward  and  downward  until  a  flap  of  this 
strong  aponeurosis  is  formed  both  above  and  below  the  hernial  open- 
ing. The  margins  of  the  neck  of  the  hernial  sac  (parietal  peritoneum), 
still  caught  in  forceps,  are  next  to  be  closed  with  sutures.    This  may 


Fig.  863. — Radical  repair  of  umbilical  hernia.  The  parietal  peritoneum  has  been 
sutured,  and  the  lower  aponeurotic  flap  (anterior  sheaths  of  the  recti  muscles)  is  being 
drawn  up  underneath  the  upper  flap  by  means  of  mattress  sutures. 


be  accomplished  by  applying  a  purse-string  (p.  881)  if  the  ring  is  small; 
but  if  it  is  large  it  is  better  to  use  interrupted  sutures.  The  sutures 
should  include  also  the  transversalis  fascia  and  the  posterior  sheaths 
of  the  recti  muscles.  Before  the  last  suture  is  tied  the  gauze  pack  is 
removed.  The  peritoneal  cavity  being  thus  closed,  the  surgeon  catches 
in  Allis  forceps  the  free  margins  of  his  aponeurotic  flaps  already 
formed  from  the  anterior  sheaths  of  the  recti  muscles.  These  flaps 
are  then  overlapped,  the  lower  one  being  pulled  up  between  the 
upper  flap  and  the  deeper  structures,  and  they  are  sutured  together 
by  interrupted  mattress  sutures  of  chromic  catgut,  as  indicated  in 
Fig.  863.  The  free  margin  of  the  upper  flap  may  then  be  sutured  to 
the  superficial  surface  of  the  anterior  rectal  sheaths. 
Transverse  suture  of  the  wound  in  repair  of  umbilical  hernia  is 


830  HERNIA 

preferable  to  longitudinal  suture  because  patients  with  umbilical 
hernia  usually  have  quite  a  pendulous  abdomen,  and  there  is  much 
more  slack  in  the  tissues  and  less  tension  on  the  sutures  if  transverse 
suture  is  adopted.  Frequently  it  is  very  difficult  if  not  impossible  to 
bring  together  the  edges  of  the  recti  by  a  longitudinal  suture,  because 
of  their  diastasis;  but  if  the  transverse  suture  with  overlapping  is 
employed  the  approximation  of  the  recti  is  unnecessary.  The  principle 
of  overlapping  fascial  layers  in  the  repair  of  hernia,  first  introduced 
in  1881  by  Lucas-Championniere,  was  adopted  by  W.  J.  Mayo  (1899) 
in  the  case  of  umbilical  hernia,  and  the  operation  as  above  described 
is  known  by  his  name.  He  has  since  adopted  modifications  of  the 
technique  introduced  by  Ochsner:  no  attempt  is  made  to  suture  the 
neck  of  the  sac  separately,  nor  are  transverse  incisions  made  in  the 
rectus  sheaths  for  the  purpose  of  forming  fascial  flaps.  The  opening 
in  the  abdomen  is  closed  simply  by  three  mattress  sutures  so  intro- 
duced as  to  draw  its  lower  margin  well  up  beneath  its  upper.  I  have 
always  used  the  original  method,  and  believe  it  is  preferable  except 
where  the  hernial  orifice  is  quite  small.  The  patient  should  be  confined 
to  bed  at  least  for  three  weeks ;  and  if  the  hernia  was  very  large  or  the 
abdomen  very  pendulous,  an  abdominal  belt  should  be  wrorn  for  several 
months.    Recurrence  is  very  unusual. 

Strangulated  Umbilical  Hernia. — This  is  a  very  serious  condition; 
the  patient  frequently  is  old,  feeble,  asthmatic,  fat,  and  arterio- 
sclerotic. The  hernia  in  most  cases  is  already  irreducible;  strangula- 
tion usually  begins  with  symptoms  of  incarceration,  and  the  develop- 
ment of  complete  strangulation  is  difficult  to  recognize,  owing  to  the 
frequency  of  intra-saccular  strangulation.  Taxis  should  not  be  per- 
sisted in  unless  the  patient  absolutely  refuses  operation.  Operation 
usually  is  too  long  delayed.  When  done,  no  attempt  should  be  made 
to  complete  the  procedure  by  repair  of  the  hernial  orifice  if  the  hernia 
has  been  long  irreducible,  or  if  the  patient's  condition  is  bad.  It  is 
sufficient  to  relieve  the"  strangulation,  and  the  herniated  structures 
may  be  left  adherent  to  the  sac,  and  should  not  be  reduced. 

Lumbar  Hernia. — This  is  quite  rare.  The  protrusion  occurs  through 
a  space  bounded  above  by  the  twelfth  rib,  medially  by  the  quadratus 
lumborum,  laterally  by  the  external  oblique,  and  below  by  the  internal 
oblique  (Grynfeltt,  1866);  this  space  transmits  the  last  intercostal 
artery  and  nerve,  which  weaken  it.  Hernia  in  Petit's  triangle  is  almost 
unknown.  The  coverings  of  the  hernia  are  skin,  superficial  fascia, 
lumbar  aponeurosis  (or  internal  oblique),  preperitoneal  fat,  and  peri- 
toneum. 

Most  of  the  cases  of  lumbar  hernia  on  record  have  been  either  con- 
genital, or  the  result  of  trauma.  Goodman  and  Speese  (1916)  collected 
12  cases  of  the  former  and  33  of  the  acquired  form.  The  condition 
presents  the  usual  symptoms  and  physical  signs  of  a  reducible  hernia 
(p.  808),  and  must  be  distinguished  from  a  cold  abscess,  as  well  as 
from  a  lipoma.  There  is  no  distinct  neck  to  the  sac.  Strangulation  is 
unusual. 


INGUINAL  HERNIA  831 

Treatment. — If  the  patient  wears  a  well-fitting  truss  for  a  year  or 
more,  there  is  fair  probability  that  a  small  hernia  may  cease  to  pro- 
trude. In  most  cases,  however,  operative  treatment  is  preferable. 
This  consists  in  dissecting  out  the  layers  of  the  abdominal  wall,  and 
overlapping  them  by  suture  whenever  this  is  possible. 

Inguinal  Hernia. — Of  the  three  usual  forms  of  hernia,  inguinal, 
femoral,  and  umbilical,  inguinal  hernia  is  by  far  the  most  frequent. 
It  comprises  about  three-fourths  of  all  cases  of  hernia,  and  is  much 
more  frequent  in  men  than  in  women.  In  males,  96  per  cent,  of 
hernia?  are  inguinal,  about  2.5  per  cent,  are  femoral,  and  only  1  per 
cent,  are  umbilical.  In  females,  50  per  cent,  are  inguinal,  33  per  cent, 
are  femoral,  and  16  per  cent,  are  umbilical  (De  Garmo). 

Nomenclature. — If  the  hernia  emerges  from  the  peritoneal  cavity 
at  the  internal  abdominal  ring,  traverses  the  inguinal  canal,  and  ap- 
pears at  the  external  abdominal  ring,  it  is  called  an  indirect  or  oblique 
inguinal  hernia.  If  it  passes  directly  through  the  abdominal  wall  on 
the  median  side  of  the  deep  epigastric  artery,  and  thus  appears  at  the 
external  ring  without  traversing  the  inguinal  canal,  it  is  called  a  direct 
inguinal  hernia.  This  is  much  rarer  than  the  indirect  form.  If  the 
hernia  remains  above  the  brim  of  the  pelvis,  it  is  called  an  incomplete 
inguinal  hernia,  or  a  bubonocele;  if  it  descends  beyond  the  brim  of  the 
pelvis  it  is  called  a  complete  inguinal  hernia.  A  complete  inguinal 
hernia  in  the  male  enters  the  scrotum  and  is  termed  a  scrotal  hernia; 
in  the  female  it  enters  the  labium  majus  and  is  called  a  labial  hernia 
(this  should  not  be  confused  with  a  pudendal  hernia,  p.  851). 

Oblique  Inguinal  Hernia. — Inguinal  hernia  is  more  frequent  in  the 
male  because  of  the  greater  size  of  the  inguinal  canal  and  because  of 
the  existence  of  the  vaginal  process  of  peritoneum  which  accompanies 
the  testicle  in  its  descent  into  the  scrotum.  These  facts  account  also 
for  the  greater  frequency  of  oblique  than  of  direct  inguinal  hernia. 
It  is  gradually  coming  to  be  recognized,  largely  owing  to  the  teaching 
of  Hamilton  Russell  (since  1899),  and  of  R.  W.  Murray,  that  most 
cases  of  hernia  are  due  to  the  existence  of  a  preformed  sac.  The  proba- 
bility of  the  existence  of  such  a  sac  is  greatest  in  the  inguinal  region; 
and  formerly  it  was  the  custom  in  describing  oblique  inguinal  hernia 
to  lay  great  stress  on  the  different  varieties  of  sac  which  might  be 
present,  according  to  the  stage  of  development  which  had  been  reached 
by  the  vaginal  process  of  peritoneum  during  fetal  life.  These  dis- 
tinctions have  little  more  than  academic  interest;  but  a  reference  to 
the  accompanying  illustrations  will  explain  the  five  forms  which  may 
be  encountered.  Occasionally  incomplete  obliteration  of  the  funicular 
process  occurs  at  one  or  more  points,  forming  fibrous  bands  or  strictures 
in  the  serous  sac  (Fig.  864) ;  this  accounts  for  cases  of  bilocular  hydro- 
cele (p.  1116),  and  is  of  some  importance  because  strangulation  may 
occur  at  any  of  these  points,  as  well  as  at  the  neck  of  the  hernial  sac. 
The  fact  of  greatest  importance  to  bear  in  mind  is  that  it  is  the  exist- 
ence of  a  preformed  sac  which  predisposes  to  development  of  hernia, 
and  that  it  is  the  extirpation  of  the  sac  which  is  the  most  important  step 


832 


HERNIA 


(especially  in  children  and  young  adults)  in  the  operation  for  the  cure 
of  hernia.  A.  IT.  Ferguson  pointed  out  that  in  some  patients  the 
internal  oblique  muscle  does  not  have  an  origin  from  Poupart's 
ligament,  as  is  normally  the  case,  and  that  this  renders  the  region  of 


Fig.  864. — Incomplete  obliteration  of 
the  funicular  process  of  peritoneum,  just 
above  the  testicle.  Found  at  operation  on 
a  patient  aged  thirty-two  years;  duration 
of  hernia  sixteen  years.  Episcopal  Hos- 
pital. 


Fig.  865. — Ordinary  adult  type  of  in- 
guino-scrotal  hernia:  fundus  of  sac 
separate  from  testicle,  and  easily  enu- 
cleated. Hernia  usually  slowly  de- 
veloped. 


the  internal  abdominal  ring  very  weak.  Torek  (1919)  insists  that  a 
weak  spot  at  the  internal  ring  exists  between  the  spermatic  vessels 
above,  and  the  vas  below.     Apart  from  these  anatomical  factors,  the 


Fig.  866. — Hernia  into  patulous  pro- 
cessus vaginalis:  there  is  no  separate 
tunica  vaginalis.  So-called  "congenital 
hernia."     A  hernia  of  sudden  formation. 


Fig.  867. — Hernia  into  funicular  pro- 
cess: fundus  of  sac  adherent  to  tunica 
vaginalis.  So-called  "infantile  hernia." 
A  hernia  of  sudden  formation. 


predisposing  and  exciting  causes  of  inguinal  hernia  are  the  same  as 
those  of  hernia  in  general  (p.  806). 

If  the  hernia  is  present  at  birth  it  is  one  usually  described  as  congenital 
(Fig.  866);  but  of  course  a  "congenital"  sac  may  be  present  but  no 


INGUINAL  HERNIA 


833 


hernia  develop  until  adult  life.  If  the  hernia  appears  at  any  time 
after  birth,  and  is  of  sudden  formation,  it  is  probable  that  there  was  a 
preformed  sac,  and  that  the  sudden  appearance  of  the  hernia  is  caused 
by  muscular  effort  forcing  some  of  the  abdominal  contents  into  this 
sac  (Fig.  867.)  If  the  hernia  is  of  slow  formation,  which  is  rare  except 
in  adults,  it  is  still  possible  that  a  small  preformed  sac  may  have 
existed. 


Fig.  868. — Hernia  encysted  into  the 
tunica  vaginalis.  The  "encysted  hernia 
of  Sir  Astley  Copper."  Funicular  process 
closed  only  at  the  internal  ring.  An  ac- 
quired hernia  of  slow  formation. 


Fig.  869. — Hernia  encysted  between 
tunica  vaginalis  and  testicle.  "Encysted 
hernia  of  Hey,  of  Leeds."  Due  to  same 
congenital  defect  as  Fig.  868,  but  parietal 
peritoneum  has  yielded  just  posterior  to 
upper  obliterated  end  of  funicular  process. 


If  the  hernia  occurs  into  a  sac  formed  by  the  patulous  vaginal 
process  of  peritoneum  (Fig.  866),  whether  the  hernia  is  present  at 
birth,  appears  during  infancy  or  childhood,  or  does  not  appear  until 
late  adult  life,  the  contents  of  the  hernia  will  obscure  the  outline  of  the 
testicle  (Fig.  870).  If,  however,  the  testicle  has  its  own  tunica  vagi- 
nalis (Figs.  865  and  867),  the  hernia  and  the  testicle  can  be  perceived  as 
separate  swellings  in  the  scrotum  (Figs.  871  and  872).  This  distinction 
is  of  some  clinical  importance,  when  operative  treatment  is  under- 
taken (p.  841).  In  all  cases,  with  very  few  exceptions,  the  hernia  lies 
in  front  of  the  spermatic  cord,  and  even  if  the  hernia  is  irreducible, 
the  cord  usually  can  be  palpated  behind  it. 

Symptoms  and  Diagnosis. — An  oblique  inguinal  hernia  is  more 
common  on  the  right  side.  It  appears  first  at  the  internal  abdominal 
ring,  and  may  or  may  not  descend  into  the  scrotum.  In  its  descent 
it  always  passes  through  the  inguinal  canal.  The  longer  its  duration 
and  the  larger  the  hernia,  the  less  oblique  becomes  its  passage 
through  the  abdominal  wall,  as  the  internal  ring  gradually  enlarges 
and  shifts  its  position  nearer  to  the  spine  of  the  pubis.  When  in  the 
scrotum  the  hernia  is  not  attached  to  the  testicle,  and  in  most  cases 
can  be  reduced  within  the  abdomen.  This  reduction  is  attended  by 
characteristic  signs  (p.  809).  If  the  hernia  is  irreducible  the  diagnosis 
may  be  more  difficult;  but  always,  unless  strangulated,  the  hernia 
53 


834 


HERNIA 


transmits  an  impulse  when  the  patient  coughs.  The  differential  diag- 
nosis of  direct  inguinal  hernia  is  considered  at  p.  843,  and  that  of 
femoral  hernia  at   p.  S46. 


1                       VI 

Fig.  <S70. — Right  oblique  inguino- 
scrotal  hernia.  Congenital  sac,  but  hernia 
developed  in  adult  life.  Outline  of  testi- 
cle obscured.  (See  Fig.  866.)  Episcopal 
Hospital. 


Fig.  871. — Right  oblique  inguino- 
scrotal  hernia,  funicular  type  (infan- 
tile). Age  sixteen  years.  Outline  of 
testicle  distinct  from  that  of  hernia. 
(See  Fig.  867.)    Episcopal  Hospital. 


An   incomplete  inguinal  hernia   must   be   distinguished   from:    (1) 
Hydrocele  of  the  cord  (p.  1117).     If  this  is  inflamed,  it  may  closely 


Fig.  872. — Right  oblique  inguino-scrotal  hernia;  age  sixteen  years;  slowly  acquired 
three  years  ago.  McBurney  incision  for  appendicitis  eight  years  ago.  (See  p.  806.) 
Outline  of  testicle  distinct  from  that  of  hernia.  (See  Figs.  865  and  875.)  Episcopal 
Hospital. 


resemble  a  strangulated  inguinal  hernia,  unless  a  clear  history  can  be 
obtained.  But  there  are  no  signs  of  intestinal  obstruction.  (2) 
Inflammatory  Lymphadenitis,  or  Inguinal  Bubo   (p.  299),  is  inflam- 


INGUINAL  HERNIA  835 

matory  in  nature,  is  irreducible;  gives  no  impulse  on  coughing;  and 
usually  a  source  of  infection  in  the  genitals,  lower  extremity,  or  buttocks 
can  be  found.  (3)  Tuberculosis  of  the  Inguinal  Lymph  Nodes  may 
resemble  an  irreducible  epiplocele;  but  the  history  of  the  onset  of  the 
two  affections  is  different;  the  swelling  lies  superficial  to  the  inguinal 
canal  and  does  not  extend  into  the  scrotum  even  if  of  long  duration; 
suppuration  is  frequent.  (4)  Cold  Abscess,  the  result  of  tuberculosis 
of  the  spine,  occasionally  makes  its  appearance  in  the  inguinal  canal; 
it  may  transmit  an  impulse  when  the  patient  coughs,  and  often  is 
reducible  when  he  lies  down;  but  the  abscess  presents  no  gurgling  on 
reduction,  and  it  is  dull  on  percussion,  which  an  enterocele  is  not; 
moreover,  examination  of  the  spine  usually  will  reveal  the  true  condi- 
tion. (5)  Undescended  Testicle  (p.  1107).  This  is  recognized  because 
the  scrotum  on  the  affected  side  is  empty,  and  because  of  the  sickening 
pain  produced  by  handling  the  tumor,  which  is  irreducible. 

A  complete  inguinal  hernia  must  be  distinguished  from:  (1)  Vaginal 
Hydrocele,  (p.  1115),  which  appears  first,  not  at  the  internal  abdominal 
ring,  but  in  the  scrotum;  which  rarely  extends  into  the  inguinal  canal; 
which  is  attached  to  the  testicle  and  is  irreducible;  which  though  cystic 
on  palpation  is  dull,  not  resonant,  on  percussion,  and  which  transmits 
light.  (2)  Congenital  Hydrocele  (p.  1115);  this  may  be  distinguished 
from  a  hernia  because  the  inguinal  canal  seems  empty  except  for  the 
cord;  because  when  reduction  occurs  there  is  no  gurgling  or  flop  of 
intestine;  because  of  the  extreme  slowness  with  which  the  scrotum 
refills  when  the  patient  stands  up;  and  because  the  hydrocele  is  dull 
on  percussion  and  is  translucent.  (3)  Varicocele  (p.  1118).  This 
appears  first  in  the  scrotum,  not  at  the  internal  abdominal  ring;  it 
may  not  extend  into  the  inguinal  canal;  it  gives  a  very  different 
impression  from  a  hernia  when  palpated;  and  though  usually  the 
swelling  disappears  when  the  patient  lies  down  and  the  scrotum  is 
elevated,  this  occurrence  is  not  attended  by  any  of  the  signs  which 
indicate  the  reduction  of  a  hernia.  (4)  Sarcocele  (p.  1114).  This  is 
formed  by  an  enlargement  of  the  testicle  itself;  it  appears  first  in  the 
scrotum;  is  irreducible;  is  dull  on  percussion  even  if  partly  cystic; 
and  though  thickening  of  the  spermatic  cord  may  occur  from  extension 
of  the  disease,  this  does  not  present  the  characteristics  of  a  hernia. 

Oblique  Inguinal  Hernia  in  the  Female. — In  women  only  the  round 
ligament  passes  through  the  inguinal  canal.  It  carries  with  it  a 
process  of  peritoneum  (the  canal  of  Nuck),  which  may  remain  patu- 
lous and  predispose  to  the  formation  of  a  hernia.  The  internal 
oblique  muscle  in  the  female,  as  a  rule,  has  a  larger  origin  from 
Poupart's  ligament  than  in  the  male,  and  no  doubt  this  lends  addi- 
tional strength  to  the  region  of  the  internal  abdominal  ring  and  the 
inguinal  canal.  In  children  a  hernia  usually  is  arrested  in  the  canal 
of  Nuck  (Fig.  873),  but  in  adults  it  often  descends  into  the  labium 
majus,  though  rarely  attaining  very  large  size. 

Strangulation  of  Oblique  Inguinal  Hernia  may  occur  in  the  neck  of  the 
sac,  at  the  internal  ring,  or  at  the  external  ring.    The  external   ring 


S3G 


HERNIA 


Fig.  873. — Bilateral  oblique  inguinal 
hernia  into  the  canal  of  Nuck,  in  a  girl 
of  nine  years.     Children's  Hospital. 


should  be  divided  first  whenever  strangulation  is  present;  the  sac  is 
then  opened;  and  it'  strangulation  is  not  relieved  by  this  means,  the 
neck  of  the  sac  and  the  internal  ring  must  be  divided  also. 

Rare  Forms  of  Oblique  Inguinal 
Hernia. — A  hernia  may  make  its  ap- 
pearance at  the  internal  abdominal 
ring,  but  for  some  reason  be  arrested 
in  its  journey  downward  to  the  scro- 
tum. This  may  be  due  to  the  ob- 
struction offered  by  an  undescended 
testicle  (occasionally  an  ovary  in  the 
female),  or  from  the  partial  constric- 
tions in  the  lumen  of  a  preformed 
sac,  to  which  reference  was  made  at 
p.  831.  (1)  If  the  hernia  is  arrested 
just  outside  of  the  internal  abdom- 
inal ring  and  forms  for  itself  a  diver- 
ticulum out  of  the  sac  wall,  between 
the  parietal  peritoneum  and  the  ab- 
dominal muscles,  it  is  called  an  in- 
guinal properitoneal  hernia  (first  well 
described  by  Kronlein  in  1880).  This 
hernia  usually  spreads  toward  the  median  line  of  the  body.  (2)  If 
it  forms  a  sac  for  itself  between  the  muscular  planes  of  the  abdominal 
wall  it  is  called  an  interstitial  or  interparietal  hernia;  this  is  the  least 
unusual  form,  and  the  hernia  generally  spreads  outward  toward  the 
crest  of  the  ilium.  (3)  If  the  hernia 
occupies  a  diverticulum  in  the  subcu- 
taneous tissues,  outside  of  the  external 
abdominal  ring,  upon  Poupart's  liga- 
ment, or  overhanging  the  upper  part  of 
Scarpa's  triangle,  it  is  known  as  a  super- 
ficial inguinal  hernia  or  an  inguino-crural 
hernia;  this  is  the  rarest  of  these  un- 
usual forms  of  hernia. 

These  hernise  are  very  liable  to  stran- 
gulation, but  the  exact  diagnosis  of  the 
condition  seldom  is  made  before  oper- 
ation. 

Unusual  Contents  of  Oblique  Inguinal 
Hernia.- — The  usual  contents  are  small 
bowel  and  omentum.  The  presence  of 
large  bowel  is  unusual.  When  present  it 
usually  forms  what  is  known  as  a  slid- 
ing hernia,  as  the  bowel  usually  slides 

down  retroperitoneally,  carrying  a  peritoneal  pouch  down  with  it, 
covering  only  its  anterior  aspect.  In  this  pouch  small  bowel  and 
omentum  may  be  contained,  and  when  these  are  reduced  at  operation, 


Fig.  874. — Sliding  hernia  of  the 
cecum :  small  intestine  in  the  her- 
nial sac.  Age  thirty-one  years; 
duration  two  years.  Episcopal 
Hospital. 


INGUINAL  HERNIA  837 

the  surgeon  will  find  that  the  posterior  wall  of  the  hernial  sac  covers 
the  large  bowel  (Fig.  874).  A  sigmoid  hernia,  occurring  on  the  left, 
is  considered  more  frequent  than  a  cecal  hernia  on  the  right.  Occa- 
sionally a  cecal  hernia  occurs  on  the  left;  in  such  cases  it  is  probable 
that  the  cecum  has  been  drawn  into  the  sac  by  the  traction  of  the 
ileum  already  in  the  sac.  The  presence  of  the  vermiform  appendix  in 
the  hernial  sac  is  of  considerable  importance,  as  it  may  become  the 
seat  of  acute  inflammation,  gangrene,  etc.  Such  cases  have  been 
carefully  studied  by  Jacquemin  (1905)  and  by  Massoulard  (1906).  An 
undescended  testicle  usually  is  accompanied  by  a  hernial  sac;  this  sub- 
ject is  discussed  at  p.  1107.  Occasionally  in  the  female  the  ovary, 
the  tube,  or  even  the  uterus  (pregnant  or  non-pregnant)  is  found  in 
the  sac  of  an  inguinal  hernia;  F.  T.  Andrews  (1905)  tabulated  366 
cases  of  this  nature. 

Treatment  of  Oblique  Inguinal  Hernia  in  Adults. — A  cure 
without  operation  is  all  but  unknown  in  adult  patients.  The  mor- 
tality of  the  operation  is  very  low,  scarcely  one  in  three  or  four  hundred 
cases;  and  the  deaths  scarcely  ever  are  due  to  the  operation  itself,  but 
to  complications,  which  may  follow  any  operation.  Recurrence  of 
the  hernia  takes  place  in  very  few  cases;  according  to  Coley,  permanent 
cure  is  effected  by  proper  operation  in  about  95  per  cent,  of  cases. 
But  when  for  any  reason  operation  is  contraindicated,  or  when  the 
patient  refuses  operative  treatment,  the  surgeon  should  know  what 
measure  of  relief  may  be  effected  by  mechanical  treatment,  and  should 
be  able  to  order  intelligently  the  proper  form  of  truss,  and  to  see  that 
it  accomplishes  the  purpose  for  which  it  is  designed. 

Trusses  for  Inguinal  Hernia. — The  pad  of  the  truss  is  to  be  applied 
over  the  inguinal  canal,  so  as  to  hold  its  superficial  and  deep  walls 
in  contact,  and  thus  to  close  the  channel  by  which  the  hernia  descends. 
The  pad  must  not  be  placed  only  over  the  external  ring,  still  less  over 
the  spine  of  the  pubis,  as  this  allows  the  hernia  to  slide  past  the  truss 
(Fig.  875).  The  pad  should  not  be  set  at  an  angle  with  the  spring  of 
the  truss  (as  in  the  bad  type  of  truss  introduced  in  1837  by  Dr.  Heber 
Chase,  and  still  in  use),  but  should  be  directly  beneath  the  spring,  so 
as  to  ensure  its  remaining  in  place  and  exerting  direct  pressure  on  the 
canal.  The  counterpressure  is  over  the  sacral  region  or  the  pos- 
terior part  of  the  buttock  of  the  opposite  side,  just  lateral  to  the 
posterior  superior  spine  of  the  ilium.  In  young  adults,  where  the 
hernia  is  small  and  easily  retained,  the  cross-body  truss  (Fig.  876)  is 
the  most  serviceable  type.  According  to  De  Garmo  this  type  was 
introduced  by  an  English  firm  of  instrument-makers  toward  the 
close  of  the  eighteenth  century.  The  spring  is  complete  in  front; 
beginning  at  the  pad  over  the  inguinal  canal,  it  passes  across  the 
pubis  from  the  affected  to  the  unaffected  side,  and  is  continued  around 
three-fourths  of  the  pelvis  to  the  buttock  of  the  affected  side.  The 
strap  holding  the  ends  of  the  spring  together  thus  lies  on  the  same  side 
of  the  pelvis  as  the  hernia.  The  pressure  made  by  the  pad  is  inward 
and  slightly  upward.    If  the  hernia  is  less  easily  retained,  or  if  the 


83S 


HERNIA 


patient  is  older  and  obese,  a  truss  with  double  pads  gives  better  sup- 
port; the  best  is  the  Hood  type  of  truss,  introduced  about  seventy-five 
years  ago  by  Dr.  J.  W.  Hood,  of  Kentucky.    The  spring  is  solid  in 


Fig.  875. — Badly  fitting  truss  of  French-German  type.  Pad  is  placed  over  spine  of 
pubis,  and  the  hernia  is  now  in  the  scrotum.  Same  patient  as  Fig.  872.  Has  worn 
truss  this  way  more  than  two  years,  in  hope  of  being  cured.    Episcopal  Hospital. 

front,  and  supports  adjustable  pads,  one  over  each  inguinal  canal 
(Fig.  877),  and  is  continued  posteriorly  on  each  side  to  within  a  few 
centimeters  of  the  spine,  where  it  is  supplied  with  two  pads  for  counter- 


Fig.  876. — Cross-body  truss,  fitting 
well.  Age  twenty-two  years.  Appen- 
dicitis operation  (rectus  incision)  one 
year  ago;  hernia  developed  six  months 
later.    Episcopal  Hospital. 


Fig.  877. — Double  Hood  truss,  applied 
for  large  left  inguinal  hernia;  light  pad 
also  on  right  side.  Age  fifty-nine  years. 
This  truss  maintains  reduction  even  in 
severe  coughing.     Episcopal  Hospital. 


pressure;  the  ends  of  the  spring  are  connected  across  the  spine  by  a 
short  strap.  This  is  also  the  best  type  of  truss  for  double  inguinal 
hernia.    The  truss  is  so  secure  that  very  little  elastic  spring  pressure  is 


INGUINAL  HERNIA 

needed  to  keep  it  in  place  and  to  retain  the  hernia,  a  fact  which  renders 
it  very  comfortable  for  the  patient  to  wear.  Other  forms  of  truss, 
the  English  rat-tail  truss,  and  the  French  and  German  trusses  are 
much  less  efficient. 

Operation  for  Oblique  Inguinal  Hernia. — Almost  every  sur- 
geon who  operates  on  many  cases  of  inguinal  hernia  develops  certain 
modifications  of  technique  peculiar  to  himself.  Many  of  these  have 
been  published  as  original  operations,  though  few  of  them  are  real 
improvements  on  the  universally  accepted  type  of  operation  which  is 
that  introduced  in  1885  by  Bassini.  This  is  the  best  operation  for  the 
average  case,  and  if  it  is  well  learned  the  operator  can  introduce  such 
improvements  as  suggest  themselves  in  special  cases  as  he  increases 
in  experience.  It  is  not  often  that  two  cases  of  hernia  are  as  alike  as 
two  peas. 

Bassini's  Operation. — The  incision  runs  above  and  parallel  to  Pou- 
part's  ligament  from  the  internal  to  the  external  abdominal  ring. 
This  incision  passes  at  once  to  the  aponeurosis  of  the  external  oblique; 
the  deep  layer  of  the  superficial  facia  (Scarpa's  fascia)  sometimes  is 
mistaken  for  this  aponeurosis.  There  will  be  cut  in  this  incision  at 
least  two  veins — the  superficial  epigastric  and  the  superficial  circum- 
flex iliac  veins.  The  four  bleeding-points  should  be  clamped  and 
ligated.  Any  other  bleeding-points  should  be  clamped  and  ligated. 
Every  bleeding-point  encountered  during  the  operation  should  be 
clamped  and  ligated.  It  is  not  sufficient  to  trust  to  forcipressure  for 
permanent  hemostasis.  The  success  of  the  operation  depends  on  the 
aseptic  healing  of  the  wound,  and  the  development  of  a  very  small 
hematoma  may  nullify  the  entire  work. 

When  the  aponeurosis  is  exposed,  the  external  abdominal  ring 
should  be  identified.  If  not  readily  apparent  it  is  easily  found  by 
raking  upward  with  the  handle  of  the  scalpel  in  the  neighborhood 
of  the  pubic  spine  (Fig.  878).  An  incision  is  next  made  through  the 
external  oblique  aponeurosis  from  the  region  of  the  internal  ring  into 
the  external  ring;  this  incision  runs  parallel  to  Poupart's  ligament 
and  at  least  1.5  cm.  above  it.  Do  not  make  the  incision  too  near 
Poupart's  ligament  or  there  will  be  no  free  margin  of  the  external 
oblique  aponeurosis  to  facilitate  subsequent  suture.  There  is  no 
advantage  in  not  cutting  through  the  pillars  of  the  external  ring. 

When  the  external  oblique  aponeurosis  has  been  incised,  its  cut 
margins  are  retracted,  by  blunt  dissection  with  the  handle  of  the 
scalpel,  until  the  inner  shelving  margin  of  Poupart's  ligament  is  well 
exposed  below,  and  the  arching  fibers  of  the  internal  oblique  can  be 
easily  seen  on  the  upper  (umbilical)  side  of  the  wound.  The  ilio- 
inguinal nerve  should  not  be  injured.  The  index  finger  is  then  passed 
down  on  the  outer  side  of  the  inguinal  canal,  close  to  Poupart's  liga- 
ment, and  hooks  up  all  the  structures  of  the  canal,  including  the 
hernial  sac  and  the  spermatic  cord  (Fig.  879).  By  a  little  skilful  dry 
dissection  the  end  of  the  finger  can  be  passed  entirely  through, 
beneath  these  structures  from  the   lower  to  the   upper  side  of  the 


840 


HERNIA 


wound.  Holding  these  structures  upon  the  left  index  finger,  the  sur- 
geon strips  its  various  coverings  off  the  hernial  sac  by  wiping  them 
away  with  gauze  or  by  the  use  of  dissecting  forceps.    As  little  cutting 


Fig.  878. — Operation  for  right  inguinal  hernia:  superficial  fascia  incised  and  bleeding- 
points  ligated.  Aponeurosis  of  external  oblique  exposed,  and  external  abdominal  ring 
identified  by  handle  of  scalpel. 


Fig.  879. — Operation  for  right  inguinal  hernia:  the  inguinal  canal  has  been  exposed  by 
an  incision  through  the  aponeurosis  of  the  external  oblique.  The  finger  is  passed  down 
close  to  Poupart's  ligament  and  hooks  up  all  the  structures  in  the  canal. 


INGUINAL  HERNIA  841 

as  possible  should  be  done,  as  this  increases  bleeding.  The  names  of 
these  deep  coverings  of  the  hernia  (intercolumnar  fascia,  i.  e.,  external 
oblique;  cremasteric  fascia),  i.e.,  internal  oblique,  and  fascia  propria, 
i.  e.,  transversalis  fascia,  have  little  more  than  academic  interest. 
The  sac  is  least  adherent  to  surrounding  structures  in  the  upper  part 
of  the  inguinal  canal,  and  it  is  best  to  isolate  it  here  first. 

When  the  sac  is  finally  bared,  it  may  be  opened,  and  its  contents 
reduced.  Then  with  one  finger  inside  the  sac,  the  surgeon  proceeds 
to  complete  its  enucleation  from  the  surrounding  tissues.1  The  sac 
is  separated  from  the  cord,  and  the  dissection  is  continued  upward 
to  the  internal  ring,  until  parietal  peritoneum  is  reached.  This  is  known 
by  the  presence  of  pre-peritoneal  fat,  and  by  the  peritoneum  becoming 
whiter,  denser,  and  more  fibrous;  and  the  operator  should  not  be 
satisfied  until  such  peritoneum  has  been  reached.  If  he  desists  before 
parietal  peritoneum  is  reached  he  will  leave  the  upper  part  of  the  sac 
behind,  in  the  form  of  a  pouch,  which  will  predispose  to  recurrence. 
The  operation  is  not  always  easy.  When  the  parietal  peritoneum  has 
been  exposed,  the  neck  of  the  sac  is  closed  by  a  purse-string  suture, 
or  if  large  by  continuous  suture,  as  in  the  case  of  any  abdominal  wound. 
It  is  not  sufficient  merely  to  ligate  the  sac  as  one  ligates  an  artery; 
such  a  ligature  is  very  apt  to  slip  off  the  neck  of  the  sac.  When  the 
neck  of  the  sac  has  thus  been  securely  sutured,  the  sac  is  cut  away, 
but  the  ends  of  the  suture  are  left  long;  the  neck  is  now  allowed  to  recede 
into  the  upper  angle  of  the  wound,  and  is  carefully  inspected  for 
bleeding;  if  this  is  found  the  neck  of  the  sac  is  drawn  again  into  full 
view  by  the  attached  suture,  and  the  bleeding-point  is  ligated  or 
controlled  by  an  additional  suture.  When  it  has  been  ascertained  that 
there  is  no  bleeding,  the  ends  of  the  suture  are  cut  short,  and  the 
surgeon  proceeds  to  close  the  inguinal  canal. 

The  spermatic  cord  is  held  out  of  the  way,  and  the  first  row  of  buried 
sutures  is  introduced.  These  sutures  are  to  approximate  the  arching 
fibers  of  the  internal  oblique  and  the  conjoined  tendon  to  the  inner 
shelving  margin  of  Poupart's  ligament,  so  as  to  form  a  new  floor  to 
the  inguinal  canal,  upon  which  the  transplanted  cord  is  to  lie.  This 
is  the  essential  feature  of  Bassini's  operation.  In  passing  these  sutures 
there  is  considerable  danger  of  wounding  the  femoral  vessels,  especially 
the  vein,  beneath  Poupart's  ligament.  These  are  mattress  sutures  of 
chromic  catgut  (No.  2  or  No.  3).  The  first  suture  is  passed  at  the 
upper  end  of  the  inguinal  canal  just  below  the  internal  ring.  The 
round-pointed  curved  needle  is  entered  from  the  superficial  aspect  of 
Poupart's  ligament  (Fig.  880),  and  emerges  (on  the  surgeon's  index 
finger  as  a  guide)  on  the  deep  and  shelving  border  of  this  ligament 
in  the  inguinal  canal.  It  is  better  to  prick  your  finger  than  to  injure 
the  femoral  vein.    The  needle  is  then  passed  beneath  the  spermatic 

1  If  the  sac  is  of  the  "congenital"  type  (Fig.  866),  its  complete  enucleation  is 
impossible.  The  fundus  should  be  left  attached  to  the  testicle,  and  may  be 
sutured,  to  form  a  tunica  vaginalis.  If  very  much  of  the  fundus  is  left,  a 
secondary  hydrocele  may  form. 


842 


HERNIA 


cord,  and  takes  a  firm  hold  of  the  internal  oblique,  passing  through  it 
from  below  upward.  The  course  of  the  needle  is  then  reversed,  passing 
first  through  the  internal  oblique  from  above  downward,  then  across 
the  inguinal  canal  beneath  the  cord,  and  finally  through  Poupart's 
ligament  from  within  outward,  to  emerge  about  half  a  centimeter 
from  its  original  point  of  entrance.  This  completes  the  first  mattress 
suture.  Usually  three  or  four  other  similar  sutures  are  required,  the 
last  sutures  drawing  the  conjoined  tendon  down  against  the  lower 
and  inner  end  of  Poupart's  ligament.  If  the  upper  end  of  the  canal 
seems  weak,  it  is  well  to  pass  the  first  suture  through  Poupart's 
ligament  and  the  internal  oblique  just  on  the  lateral  (flank)  side  of  the 
internal  ring.  By  passing  all  these  deep  sutures  as  described,  the 
knots  are  brought  entirely  outside  the  inguinal  canal.  This  is  an 
advantage. 


Fig.  880. — Operation  for  right  inguinal  hernia:  suturing  the  arching  fibers  of  the  internal 
oblique  (beneath  the  cord)   to  Poupart's  ligament. 


The  spermatic  cord  is  now  replaced  on  the  superficial  surface  of  the 
internal  oblique,  and  the  cut  margins  of  the  external  oblique  aponeu- 
rosis are  then  sutured,  over  the  cord,  with  a  continuous  suture  (the 
second  row  of  buried  sutures)  from  above  downward,  leaving  an  opening 
below  (the  new  external  ring)  just  large  enough  to  transmit  the  cord 
(Fig.  881).  The  skin  wound  is  then  closed  in  the  usual  way.  The 
patient  should  remain  in  bed  two  weeks,  and  if  the  hernia  was  large, 
or  if  more  than  one  hernia  was  operated  on,  for  three  wreeks  or  longer. 

In  women  the  operation  is  simpler,  since  there  is  no  cord  in  the  way. 
The  canal  may  be  completely  closed,  the  round  ligament  being  included 
in  the  sutures. 

In  infants  the  use  of  a  truss  for  a  year  or  more  will  cure  a  small 
hernia  in  a  fair  proportion  of  cases — De  Garmo  says  in  95  per  cent. 


DIRECT  INGUINAL  HERNIA 


843 


But  this  means  that  the  truss  fits,  that  it  is  changed  from  time  to  time 
as  the  child  grows,  that  the  patient  is  under  constant  surgical  super- 
vision, and  that  the  truss  is  employed  with  all  the  precautions  enumer- 
ated at  page  811.  Unless  these  conditions  are  fulfilled,  and  they 
rarely  are,  a  cure  need  not  be  expected.  But,  as  a  rule,  it  is  not  desir- 
able, though  perfectly  possible,  to  resort  to  operation  on  a  child  until 
it  has  learned  to  control  its  bladder  and  bowels.  The  youngest  patient 
I  have  operated  on  was  a  boy,  six  weeks  old,  with  strangulated  hernia; 
he  was  not  confined  to  bed  after  the  operation,  and  did  perfectly  well. 
In  young  children  complete  extirpation  of  the  sac  is  sufficient  to  ensure 
against  recurrence;  it  is  not  necessary  to  transplant  the  cord,  and 
if  it  is  short  it  may  be  impossible  to  do  so.  If  the  inguinal  canal  seems 
weak,  the  other  steps  of  the  operation  are  the  same  as  in  the  Bassini 
operation.  This  form  of  operation,  without  transplanting  the  cord, 
was  employed  also  in  adults  by  A.  H.  Ferguson  (1899),  and  is  known 
as  Ferguson's  method. 


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Fig. 


11. — Operation  for  light  inguinal  hernia:  the  aponeurosis  of  the  external  oblique 
is  sutured  over  the  cord. 


Direct  Inguinal  Hernia. — This  hernia  is  one  which  protrudes  through 
the  abdominal  wall  on  the  median  side  of  the  deep  epigastric  artery, 
just  to  the  outer  side  of  the  spine  of  the  pubis,  and  directly  behind 
the  external  abdominal  ring.  This  is  the  space  known  as  Hesselbach's 
triangle.  Direct  hernia  is  seen  about  once  in  every  30  to  40  cases  of 
indirect  inguinal  hernia.  It  is  least  rare  in  adults  and  occurs  oftener 
in  men  than  in  women.  It  is  a  hernia  of  slow  formation,  and  there 
is  no  well  defined  neck  to  the  sac.  In  most  cases  it  may  be  recognized 
at  a  glance  (Fig.  882).  Strangulation  is  very  unusual.  It  is  distin- 
guished from  oblique  inguinal  hernia  by  the  fact  that  when  it  has  been 
reduced,  pressure  over  the  internal  abdominal  ring  does  not  prevent 
its  reappearance.     It  should  not  be  forgotten  that  a  large  indirect 


Nil 


HERNIA 


Fig.  882. — Double  direct  inguinal  hernia, 
age  sixty-eight  years;  duration  thirty  years. 
Of  slow  onset,  from  constant  straining  in 
urination.  Has  strictures  of  urethra,  and 
enlarged  prostate.  Operation  on  hernise 
contraindicated  until  urinary  obstruction  is 
relieved.     Episcopal  Hospital. 


inguinoserotal  hernia  may  cause  the  position  of  the  internal  abdominal 
ring  to  shift  until  it  lies  directly  behind  the  external  ring;  but  a  direct 
hernia  never  descends  far  into  the  scrotum.     Sometimes  when  the 

hernia  is  reduced,  it  is  possible 
to  palpate  the  deep  epigastric 
artery  on  the  lateral  margin  of 
the  hernial  orifice.  If  there  is 
any  doubt  about  the  nature  of 
the  hernia,  it  probably  is  an 
indirect  inguinal  hernia. 

A  direct  hernia  usually  pro- 
trudes through  the  conjoined 
tendon,  which  is  carried  forward 
as  one  of  its  coverings.  Occa- 
sionally, however,  it  passes  to 
the  outer  side  of  the  conjoined 
tendon.  In  most  cases  the  sper- 
matic cord  lies  on  the  outer  side 
of  the  sac. 

Rare  Forms  of  Direct  Inguinal 
Hernia. — Sometimes  the  sac  of  a 
direct  inguinal  hernia  occupies 
(1)  a  properitoneal  position  near 
the  bladder ;  or  after  protruding  through  the  conjoined  tendon  on  the 
median  side  of  the  obliterated  umbilical  vein,  it  may  lie  (2)  between 
the  conjoined  tendon  and  the  external  oblique  aponeurosis,  or  (3)  in  a 
subcutaneous  position  in  front  of  the  external  oblique  aponeurosis. 
For  these  rare  varieties  of  direct  inguinal  hernia  Reich,  in  1909,  pro- 
posed the  name  of  Supravesical  Hernia.  He  collected  16  cases  of  the 
first  variety,  whieh  he  calls  internal  supravesical  hernia;  and  26  cases 
of  the  second  and  third  varieties,  which  he  terms  external  supravesical 
hernia. 

Treatment  of  Direct  Inguinal  Hernia. — If  a  truss  is  used,  it  must 
have  a  large  pad,  as  the  hernia  is  difficult  to  control.  Repair  of  the 
defect  by  operation  is  also  more  difficult  and  is  less  sure  in  preventing 
recurrence  than  in  indirect  inguinal  hernia.  The  parts  are  exposed 
in  the  same  way,  and  the  sac  is  isolated.  In  doing  this  the  surgeon 
should  remember  that  the  bladder  frequently  protrudes  into  Hessel- 
bach's  triangle,  and  that  its  extraperitoneal  surface  is  with  difficulty 
distinguished  from  preperitoneal  fat.  Any  fatty  mass  toward  the 
median  side  of  the  hernial  orifice  should  be  avoided.  When  the  sac 
has  been  opened  and  its  contents  have  been  reduced,  it  will  be  found 
that  an  opening  is  left  which  it  is  difficult  to  suture  firmly,  owing  to 
the  relaxed  and  atrophied  condition  of  the  various  layers  of  the  abdomi- 
nal wall.  After  the  parietal  peritoneum  has  been  sutured,  the  inter- 
nal oblique  and  conjoined  tendon  should  be  drawn  down  if  possible 
and  sutured  to  Poupart's  ligament,  underneath  the  spermatic  cord, 
as  in  the  Bassini  operation  (p.  839).     In  cases  where  the  internal 


FEMORAL  HERNIA  845 

oblique  and  conjoined  tendon  are  very  weak,  the  median  reflected 
flap  of  the  external  oblique  aponeurosis  may  be  included  in  the  sutures 
with  them,  and  be  drawn  down  and  sutured  to  Poupart's  ligament 
beneath  the  spermatic  cord;  then  the  lateral  reflected  flap  of  the 
external  oblique  is  sutured  over  the  cord  (E.  Wyllys  Andrews,  1895). 
If  the  cremaster  is  well  developed  it  may  be  employed  as  an  additional 
layer  in  suturing  the  canal.  Another  plan  may  be  adopted  where 
the  conjoined  tendon  is  so  thin  that  it  will  not  hold  the  sutures;  an 
incision  is  made  through  the  transversalis  fascia  along  the  lateral 
border  of  the  conjoined  tendon,  raising  it  and  the  anterior  sheath  of 
the  rectus  off  this  muscle,  whose  fibers  are  then  drawn  over  and  sutured 
to  Poupart's  ligament  (Bloodgood,  1898).  When,  as  is  often  the  case, 
the  sac  is  blended  with  the  much  relaxed  overlying  structures,  no 
attempt  should  be  made  to  separate  them,  but  G.  G.  Davis's  operation 
(1905)  should  be  employed:  these  blended  tissues  are  divided  trans- 
versely, and  are  overlapped  from  above  downward,  much  as  in  Mayo's 
operation  for  umbilical  hernia  (p.  829).  This  gives  very  satisfactory 
closure.  The  use  of  a  free  fascial  flap,  as  noted  on  p.  826  may  be 
desirable  in  some  cases. 

However  the  deeper  structures  are  sutured,  the  skin  is  closed  in 
the  usual  way,  and  after-treatment  is  conducted  as  after  operations 
for  indirect  inguinal  hernia. 

Femoral  Hernia. — Femoral  or  Crural  Hernia  has  also  been  termed 
merocele.  The  hernia  protrudes  through  the  femoral  canal,  beneath 
Poupart's  ligament,  on  the  median  side  of  the  femoral  vein.  As 
already  noted,  it  is  commoner  in  women  than  in  men,  especially  in 
women  after  the  menopause.  In  childhood  it  is  rare.  Though  in  most 
cases  there  is  a  preformed  sac,  this  may  not  always  be  a  congenital 
deformity,1  but  may  be  a  traction  diverticulum  probably  due  to  the 
fact  that  some  of  the  preperitoneal  fat  is  forced  into  the  femoral  canal 
and  gradually  draws  the  peritoneum  after  it.  Such  a  sac  may  exist 
for  many  years  before  a  hernia  forms;  Murray  found  this  condition 
in  48  out  of  200  cadavers.  Most  of  the  femoral  hernia?  I  have  seen 
have  been  of  sudden  formation,  clearly  indicating  the  previous 
existence  of  a  sac. 

As  the  hernia  develops,  it  carries  before  it  preperitoneal  fat  (septum 
crurale)  and  transversalis  fascia  (crural  sheath).  While  still  in  the 
femoral  canal  it  is  known  as  an  incomplete  femoral  hernia.  Increasing 
in  size,  it  leaves  the  femoral  canal,  causes  bulging  of  the  cribriform 
fascia,  and  curves  upward  over  the  falciform  process  of  fascia  lata,  and 
lies  beneath  the  skin  of  the  groin  (complete  femoral  hernia).  It  seldom 
grows  very  large.  The  only  contents  of  the  sac  often  is  omentum, 
but  neither  this  nor  intestine  is  likely  to  become  irreducible  without 
becoming  at  the  same  instant  strangulated.  Strangulation  probably 
is  more  frequent  in  femoral  than  in  any  other  form  of  hernia,  and 

1  According  to  Lockwood,  a  congenital  sac  in  the  femoral  canal  is  to  be  attrib- 
uted to  traction  by  aberrant  strands  of  the  gubernaculum  testis. 


846  HERNIA 

gangrene  occurs  more  rapidly,  owing  to  the  sharp  margins  of  the 
femoral  canal.  Small  intestine  is  much  more  frequently  present  in 
the  sac  than  the  colon,  but  the  cecum  sometimes  is  found;  A.  C.  Wood 
(1900)  collected  100  cases  in  which  the  vermiform  appendix  was  the 
only  structure  in  the  sac. 

Rare  Forms  of  Femoral  Hernia. — The  sac  of  a  femoral  hernia  may  have 
one  or  more  diverticula,  and  such  cases  have  been  described  as  sepa- 
rate forms  of  femoral  hernia:  there  are  recognized  (1)  a  diverticulum 
through  the  cribriform  fascia,  or  hernia  of  Ilesselbach  (1816);  (2)  a 
diverticulum  through  the  superficial  fascia,  or  hernia  of  Cooper  (1807); 
(3)  a  properitoneal  diverticulum,  or  hernia  of  Tessier  (1834).  A  more 
frequent,  but  still  very  rare  variety,  is  called  a  pectineal  hernia,  or 
hernia  of  Cloquet  (1814);  in  this  the  sac  passes  from  the  femoral  ring 
between  the  pectineus  muscle  and  its  sheath,  instead  of  anterior  to 
the  latter  as  in  the  usual  form;  if  large  the  sac  may  extend  outward 
beneath  the  femoral  vessels.  Ulrichs  (191 1)  referred  to  15  cases  of  this 
variety  of  femoral  hernia  which  was  well  studied  in  1907,  by  Dege. 
This  hernia  is  to  be  distinguished  from  another  rare  variety,  in  which 
the  sac  enters  the  sheath  of  the  femoral  vessels,  and  passes  into  the 
thigh  behind  them  (hernia  retrovascularis) .  There  have  been  recorded 
also  a  few  cases  of  femoral  hernia  external  to  the  femoral  vessels,  between 
the  ilio-pectineal  ligament  and  the  femoral  artery  (hernia  of  Partridge, 
1846).  A  hernia  through  an  opening  in  Gimbernat's  ligament  was 
described  first  by  Laugier  (1833)  and  is  known  by  his  name;  it  is  on  the 
median  side  of  the  obliterated  umbilical  artery. 

Diagnosis. — A  femoral  hernia  is  to  be  distinguished  from  other  forms 
of  hernia,  from  enlarged  lymph  nodes,  from  subcutaneous  lipoma, 
from  varices  of  the  saphenous  vein,  and  from  psoas  abscess. 

1.  An  inguinal  hernia  appears  first  above  Poupart's  ligament,  and 
can  be  retained  within  the  abdomen,  after  reduction,  by  pressure  over 
the  inguinal  canal.  A  femoral  hernia  always  makes  its  first  appear- 
ance below  Poupart's  ligament,  and  it  will  not  be  retained  within  the 
abdomen  if  pressure  is  made  only  over  the  inguinal  canal.  If  the  hernia 
is  irreducible  the  diagnosis  is  more  difficult;  but  if  an  imaginary  line 
is  drawn  from  the  spine  of  the  pubis  to  the  anterior  superior  spine  of 
the  ilium,  it  is  safe  to  say  that  a  hernia  whose  chief  bulk  lies  below 
that  line  (which  corresponds  to  Poupart's  ligament)  is  a  femoral 
hernia  (Fig.  883). 

2.  If  an  obturator  hernia  is  present,  the  femoral  canal  will  be  empty, 
which  is  never  the  case  if  a  femoral  hernia  exists. 

3.  In  femoral  adenitis  the  swelling  may  occur  over  the  femoral  canal, 
but  it  transmits  no  impulse  on  coughing;  moreover,  it  presents  signs 
of  inflammation  and  a  primary  source  of  infection  usually  can  be 
found.  But  as  a  strangulated  femoral  hernia  may  be  present  behind 
inflamed  lymph  nodes,  it  is  safer  to  operate  in  cases  of  doubt.  The 
same  is  true  in  cases  of  fatty  or  other  tumors  overlying  the  femoral  canal. 

4.  A  varicosity  of  the  long  saphenous  vein  may  protrude  over  the 
femoral  canal.     It  transmits  an  impulse  when  the  patient  coughs, 


FEMORAL  HERNIA 


847 


but  though,  like  a  hernia,  it  disappears  when  the  patient  lies  down, 
its  reduction  is  not  attended  by  gurgling,  nor  when  the  patient  stands 
up  will  its  reappearance  be  prevented  by  pressure  over  the  femoral 
canal. 

5.  A  psoas  abscess  is  secondary  to  tuberculosis  of  the  spine,  which 
usually  may  be  detected  by  proper  examination.  When  the  abscess 
descends  below  Poupart's  ligament  it  usually  appears  on  the  outer 
side  of  the  femoral  vessels.  Though  it  may  transmit  an  impulse  on 
coughing,  and  may  be  reducible,  this  reduction  is  not  attended  by  the 
gurgling  so  characteristic  of  hernia. 


Fig.  8S3. — Right  femoral  hernia.     Episcopal  Hospital. 

Treatment  of  Femoral  Hernia. — The  use  of  a  truss  is  unsatisfactory 
even  in  retaining  the  hernia  within  the  abdomen,  as  it  is  impossible 
to  obliterate  the  femoral  canal;  the  most  that  a  truss  can  do  is  to  close 
its  lower  (crural)  opening.  No  cure  without  operation  need  be  antici- 
pated; and  in  no  form  of  hernia  is  a  cure  so  necessary,  owing  to  the 
great  frequency  with  which  strangulation  occurs. 

1.  The  usual  operation  is  done  by  the  femoral  route.  The  skin 
incision  may  be  straight,  in  the  long  axis  of  the  body,  directly  over  the 
femoral  canal,  or  a  flap  may  be  outlined,  convex  outward,  so  that  the 
line  of  skin  sutures  will  be  far  removed  from  the  genitalia  (Fig.  884). 
The  incision  should  commence  well  above  Poupart's  ligament,  and 
should  expose  also  the  fascia  lata  and  cribriform  fascia  over  the  upper 
part  of  Scarpa's  triangle.  Care  should  be  taken  not  to  wound  the 
long  saphenous  vein.  When  the  skin  and  subcutaneous  tissues  have 
been  reflected,  the  sharp  margin  of  the  falciform  process  of  the  fascia 
lata  is  to  be  located.  Beneath  this  the  femoral  artery  will  be  felt 
pulsating,  and  to  the  median  side  of  this  is  the  femoral  vein  which  is 
in  constant  danger  of  injury.  On  the  median  side  of  the  wound  the 
surgeon  should  identify  the  pectineus  muscle  and  its  fascia.  Then 
the  sac  may  be  opened.  If  the  hernia  is  large  and  irreducible,  which 
is  seldom  the  case,  it  may  be  impossible  to  identify  these  various 
structures  until  the  sac  has  been  opened  and  its  contents  reduced. 
Under  such  circumstances  the  operator  must  cut  down  layer  by  layer 


sis 


HERNIA 


until  the  sac  is  opened.  It  is  seldom  possible  to  identify  the  various 
coverings  of  the  hernia.  The  omentum  in  an  irreducible  femoral  hernia 
nearly  always  requires  to  be  excised  in  entirety.  When  the  contents 
of  the  sac  have  been  reduced,  the  sac  must  be  traced  up  into  the  femoral 
canal  under  Poupart's  ligament  until  parietal  peritoneum  is  reached. 
This  is  known  by  its  being  whiter,  denser,  and  more  fibrous  than  the 
walls  of  the  hernial  sac.  The  opening  in  the  parietal  peritoneum  is 
then  closed  with  a  purse-string  suture,  and  the  sac  is  cut  away,  with 
the  usual  precautions  against  overlooking  hemorrhage  from  the 
stump  (p.  841).  From  recent  observations  (Ochsner)  it  seems  probable 
in  most  cases  of  femoral  hernia,  except  where  the  femoral  canal  is 
widely  dilated,  that  accurate  suture  of  the  parietal  peritoneum  is  a 
sufficient  preventative  of  recurrence,  even  without  any  attempt  to  close 


Fig.  884. — Incisions  for  femoral  hernia:     a  a',  for  the  inguinal  method;  b  b',  longi- 
tudinal incision  for  the  crural  method;  c  c',  flap  incision  for  the  crural  method. 

the  femoral  canal  by  suture.  But  in  most  cases  it  is  not  very  difficult 
to  insert  one  or  more  sutures  so  as  to  obliterate  the  canal.  The  needle 
(curved  and  round  pointed),  threaded  with  chromic  catgut,  is  entered 
on  the  superficial  surface  of  Poupart's  ligament,  close  to  the  femoral 
vein,  and  is  made  to  emerge  in  the  femoral  canal,  catching  some  of  the 
fibers  of  the  sheath  of  the  femoral  vein  if  possible  to  do  this  without 
puncturing  the  vein.  The  needle  is  again  gripped  in  the  needle-holder, 
and  is  passed  transversely  inward,  taking  a  firm  hold  of  the  pectineal 
fascia  and  underlying  muscle,  and  is  again  gripped  in  the  needle-holder. 
The  needle  is  then  passed  through  Poupart's  ligament  from  below 
upward,  near  its  inner  end,  and  emerges  finally  near  its  original  point 
of  entrance  on  the  superficial  aspect  of  Poupart's  ligament.  This 
completes  the  first  purse-string  suture  of  the  femoral  canal  (Fig.  885) . 
If  there  is  room,  a  second  similar  suture  may  be  passed  nearer  the  lower 
(crural)  orifice  of  the  femoral  canal.     When  these  sutures  are  tied, 


FEMORAL  HERNIA 


849 


Poupart's  ligament  is  pulled  down  against  the  pectineal  fascia,  and 
the  femoral  canal  is  closed.  The  needle  always  should  be  introduced 
first  on  the  side  of  the  canal  where  the  femoral  vein  lies,  as  there  is 
thus  less  danger  of  injury  to  this  important  structure.  The  skin  wound 
is  then  closed  in  the  usual  way. 

2.  The  inguinal  route  for  operation  in  cases  of  femoral  hernia,  intro- 
duced, in  1892,  by  Ruggi,  does  not  seem  to  have  been  employed  much 
in  this  country,  though  it  possesses  many  ad- 
vantages, which  I  shall  mention  after  briefly 
describing  the  operation.    The  skin  incision  is 
the  same  as  in  the  operation  for  inguinal  hernia 
(Fig.  884,    a  a'),   and   the  external  oblique  is 
divided,  freely  exposing  the  inguinal  canal.  The 
lower  border  of  the  internal  oblique  and  the  con- 
joined tendon  (with  the  spermatic  cord  or  round 
ligament)  are  then  pulled  upward  and  toward 
the  median  line  by  a  retractor,  drawing  the 
transversalis   fascia  tense,    and   exposing  the 
superficial   aspect  of   Hesselbach's   triangle — 
bounded  below  by  Poupart's  ligament,  inter- 
nally by   the   conjoined  tendon,   and  on  the 
outer  side  by  the  deep  epigastric  artery  (Fig. 
886).    The  transversalis  fascia  is  then  incised 
on  the  inner  side  of,  and  parallel  to,  the  deep 
epigastric  vessels.     This  at  once  exposes  the 
pouch  of  peritoneum,  as  it  enters  the  upper 
(abdominal)  orifice  of  the  femoral  canal,  to 
form  the  femoral  hernia.    It  lies  just  to  the 
median  side  of  the  external  iliac  vein,  in  full 
view.    The  hernial  sac  is  then  drawn  out  of  the  femoral  canal,  and 
into  the  inguinal  wound.    It  is  opened  and  its  contents  are  reduced. 
It  is  then  easy  to  close  by  suture  the  opening  in  the  parietal  perito- 
neum well  above  the   neck  of  the  sac.     These   steps  having   been 
accomplished,  the  surgeon  may  insert   a  purse-string  suture  in  the 
femoral  canal,  precisely  as  in  the  crural  method  of  operation,  except 
that  the  steps  of  this  suturing  are  under  better  control  of  the  eye. 
Poupart's  ligament  is  pulled  down  by  the  sutures  against  Cooper's 
ligament,  firmly  closing  the  femoral  canal  at  its  abdominal  opening 
(Fig.  887).    Or,  the  internal  oblique  and  conjoined  tendon  may  be 
sutured   beneath   the  cord   to  Cooper's   ligament    (Lotheisen,  1898). 
The  operation  is  then  concluded,  as  in  cases  of  indirect  inguinal  hernia. 

I  have  employed  this  inguinal  method  for  the  treatment  of  femoral 
hernia  for  many  years,  and  regard  it  as  superior  in  every  way  to 
the  femoral  route.  It  is  simpler,  easier,  and  I  believe  also  safer.  In 
uncomplicated  cases  it  enables  the  surgeon  to  excise  all  of  the  sac, 
the  whole  of  which  is  readily  drawn  up  into  the  inguinal  wound;  and 
it  ensures  closure  of  the  parietal  peritoneum  without  leaving  a  pouch 
which  will  predispose  to  recurrence.  In  complicated  cases  it  gives 
54 


Fig.  885. — Crural  oper- 
ation for  right  femoral 
hernia:  closing  the  fem- 
oral canal. 


850 


HERNIA 


much  freer  exposure  of  the  parts,  and  renders  the  surgeon  master  of 
the  situation:  if  there  is  strangulation,  the  constriction  is  much  more 
readily  found  and  easily  divided;  if  there  is  an  anomalous  distribution 
of  the  obturator  artery,  it  is  easily  discovered,  and  accidental  hemor- 
rhage may  be  promptly  controlled;  if  the  gut  is  gangrenous,  and 
intestinal  resection  or  anastomosis  is  required,  these  may  be  done  much 
more  rapidly  and  safely  than  by  the  femoral  method.  By  the  latter 
route  Gimbernat's  ligament,  the  usual  point  of  constriction,  cannot 
be  divided  under  control  of  the  eye;  it  may  be  impossible,  owing  to 
shortness  of  the  mesentery,  to  draw  down  enough  healthy  bowel  to 
perform  a  resection,  and  even  when  the  anastomosis  is  accomplished, 


Fig.  886. — Inguinal  operation  for 
right  femoral  hernia:  the  aponeurosis 
of  the  external  oblique  has  been 
divided,  exposing  the  inguinal  canal. 
Tin;  transversalis  fascia  has  been 
divided,  exposing  the  sac  of  the 
hernia  entering  the  femoral  ring. 


Fig.  887. — Inguinal  operation  for  right 
femoral  hernia:  the  sac  has  been  removed 
and  the  parietal  peritoneum  sutured; 
Poupart's  ligament  is  now  being  sutured 
to  Cooper's  ligament.  Gimbernat's  liga- 
ment in  full  view. 


if  one  is  required,  it  may  be  impossible  to  return  the  gut  through  the 
narrow  femoral  canal.  The  only  alternative  in  such  cases  is  to  divide 
Poupart's  ligament,  a  procedure  which  renders  recurrence  of  the 
hernia  almost  certain,  and  in  a  form  which  it  is  extremely  difficult 
to  cure.  Should  there  be  a  fecal  abscess  in  the  sac,  however,  it  should 
be  drained  through  a  femoral  incision  before  the  inguinal  operation 
is  begun.  The  peritoneal  cavity  also  should  be  well  protected  by  gauze- 
packs  before  the  gangrenous  gut  is  reduced.  If  it  proves  impossible 
to  draw  the  sac  up  into  the  inguinal  canal,  its  neck  should  be  opened 
and  its  contents  should  receive  appropriate  treatment.  Under  these 
circumstances  the  fundus  of  the  sac  may  be  allowed  to  remain  in  the 
femoral  canal. 


PERINEAL,   PUDENDAL  AND  VAGINAL  HERNIA  851 

Obturator  Hernia. — This  is  very  rare.  Berger  found  it  once  among 
10,000  cases  of  hernia.  About  200  cases  are  on  record.  It  is  most  fre- 
quent in  elderly  women.  It  is  a  hernia  of  slow  formation.  The  sac 
leaves  the  pelvis  through  the  obturator  foramen,  and  protrudes  in 
the  upper  inner  part  of  Scarpa's  triangle,  underneath  the  pectineus 
muscle,  where  the  hernia  can  be  more  easily  felt  than  seen.  The  thigh 
should  be  flexed,  adducted,  and  rotated  slightly  outward:  then  the 
surgeon  places  his  finger  against  the  descending  ramus  of  the  pubis 
behind  the  adductor  longus,  and  palpates  carefully  for  the  swelling 
(Macready).  The  two  limbs  should  be  conipared.  Sometimes  both 
sides  are  affected.  The  sac  usually  contains  bowel,  but  the  tube  and 
ovary  have  been  present  in  a  few  cases.  The  existence  of  a  hernia 
seldom  is  recognized  until  strangulation  occurs,  and  even  then  the 
true  cause  of  the  symptoms  may  be  overlooked. 

Diagnosis. — The  diagnosis  in  a  case  of  strangulation,  apart  from  the 
symptoms  of  intestinal  obstruction,  would  depend  on  the  history  of 
previous  attacks  of  incarceration  of  the  hernia,  with  relief  of  pain 
coincident  with  the  sensation  of  something  slipping  back  into  the 
pelvis;  the  onset  of  the  present  symptoms  with  sudden  pain  in  the 
region  of  the  obturator  foramen;  on  the  radiation  of  pain  in  the  dis- 
tribution of  the  obturator  nerve;  and  on  the  discovery  of  a  tender 
swelling  beneath  the  pectineus  muscle,  by  the  mode  of  examination 
already  indicated,  together  with  palpation  of  the  inner  surface  of  the 
obturator  foramen  through  the  vagina  or  rectum. 

Treatment. — Treatment  consists  in  laparotomy  and  reduction  of  the 
hernia,  with  closure  of  the  obturator  canal  by  suture.  The  mortality 
has  been  about  85  per  cent.,  largely  because  the  condition  has  not  been 
recognized  in  time. 

Perineal,  Pudendal  and  Vaginal  Herniae. — Pelvic  hernia  is  extremely 
rare.  It  is  probable  that  congenital  anomalies  of  the  pelvic  peri- 
toneum (possibly  preformed  pouches)  predispose  to  its  development. 
It  occurs  about  six  times  as  often  in  women  as  in  men.  In  the  male 
the  protrusion  occurs  in  the  perineum  {perineal  hernia),  between 
rectum  and  prostate,  or  rarely  in  the  ischio-rectal  fossa.  It  may 
be  associated  with  prolapse  of  the  rectum.  In  the  female  the  hernia 
may  leave  the  pelvis  behind  or  in  front  of  the  broad  ligament.  In 
the  former  case  he  protrusion  may  occur  in  the  perineum,  in  the 
ischio-rectal  fossa,  or  in  the  posterior  vaginal  wall  {vaginal  hernia). 
Vaginal  hernia  u  ually  is  associated  with  procidentia  uteri.  If  the 
hernia  leaves  the  pelvis  in  front  of  the  broad  ligament,  as  is  more 
often  the  case,  it  enters  the  labium  majus  (pudendal  hernia,  Fig.  888), 
where  it  must  be  distinguished  from  (1)  an  inguino-labial  hernia, 
which  passes  above  the  brim  of  the  pelvis,  through  the  inguinal  canal; 
and  from  (2)  a  femoral  hernia,  which  also  leaves  the  abdomen  above 
the  brim  of  the  pelvis,  and  which  has  the  neck  of  its  sac  external, 
not  internal,  to  the  descending  ramus  of  the  pubis. 

Treatment. — Treatment  usually  is  palliative,  by  the  application  of 
a  suitable  .pessary,  T-bandage,  or  other  appliance.     Strangulation  is 


852 


HERNIA 


rare.  Operation  is  undertaken  only  when  the  hernia  forms  a  com- 
plication of  another  condition,  such  as  prolapse  of  the  rectum,  vagina, 
or  uterus. 


Fig.  888. — Left  pudendal  hernia,  containing  ovary,  in  a  woman  of  eighty  years.     Diag- 
nosis at  operation  (symptoms  of  strangulation).    Recovery.    Episcopal  Hospital. 

Ischiatic  Hernia. — These  are  also  extremely  rare  forms  of  hernia. 
Koppl  (1908)  collected  23  cases.  He  prefers  Waldeyer's  classifica- 
tion: (1)  Hernia  Ischiadica  Suprapyriformis.  (2)  Hernia  Ischiadica 
Infrapyriformis.  (3)  Hernia  Ischiadica  Spinotuberosa.  The  first  and 
second  forms  occur  through  the  greater  sacrosciatic  foramen  (11  cases 
above,  and  7  below  the  pyriformis  muscle) ;  the  third  form  (only  one 
case  recorded)  occurs  through  the  lesser  sacrosciatic  foramen.  In  four 
of  the  recorded  cases  the  particular  form  was  not  described. 

These  hernia?  occur  into  a  preformed  sac,  either  congenital,  or  formed 
by  the  traction  of  a  gluteal  lipoma,  myxoma,  or  other  tumor.  They 
make  their  external  appearance  along  the  perineal  border  of  the 
gluteus  maximus  muscle,  and  it  is  difficult  to  distinguish  them  from 
perineal  hernia.  If  strangulation  occurs,  the  swelling  should  be 
explored  and  drained  from  below;  then  the  abdomen  should  be  opened, 
and  the  gut  reduced.  The  general  mortality  of  the  reported  cases  is 
34  per  cent. 


CHAPTER  XXII. 

ABDOMINAL  SURGERY  IN  GENERAL,  AND  INJURIES  OF 
THE  ABDOMINAL  VISCERA. 

THE  PERITONEUM. 

The  large  serous  sac  known  as  the  peritoneum  is  of  immense  impor- 
tance in  surgery.  It  forms  the  omentum  and  mesenteries,  and  covers 
closely  the  gastro-intestinal  tract,  and  less  completely  the  liver,  gall- 
bladder, and  pancreas,  as  well  as  the  spleen,  kidneys,  bladder,  and 
female  organs  of  generation.  Its  total  area  is  said  to  exceed  that  of 
the  skin  which  covers  the  surface  of  the  body.  There  is  present 
normally  a  small  amount  of  fluid,  just  sufficient  to  lubricate  the  endo- 
thelial surfaces.  This  fluid  or  any  extraneous  material  introduced 
into  the  peritoneal  cavity  is  absorbed  largely  in  the  region  of  the 
upper  abdomen,  especially  through  the  peritoneum  lining  the  under 
surface  of  the  diaphragm.  It  is  believed  that  a  constant  upward 
current  exists  from  the  peritoneal  cavity  through  the  diaphragm  to 
the  mediastinal  lymph  nodes;  and  absorption  of  intraperitoneal  exu- 
dates occur  much  more  rapidly  by  this  route  than  through  the  mesen- 
teric lymph  nodes  which  drain  the  mucous  surfaces  of  the  abdominal 
viscera.  Absorption  from  the  peritoneal  cavity  is  hindered  largely  by 
a  faculty  which  the  peritoneum  possesses  in  common  with  all  serous 
membranes — that  of  forming  adhesions.  In  cases  of  infection  of  the 
peritoneum  by  bacteria  and  their  toxins,  the  injury  to  the  endothelial 
surface  of  the  peritoneum  is  sufficient  in  most  cases  to  cause  adhesion 
between  adjacent  serous  surfaces,  and  it  is  in  this  way  that  infectious 
processes  are  localized.  While  this  results  in  encapsulation  of  an 
infecting  focus,  it  also  entails  a  certain  amount  of  impairment  of 
function  in  interference  with  peristalsis.  Isohtion  of  an  infected  area 
is  favored  by  the  insertion  of  gauze  packs,  which  will  within  a  few 
days  excite  adhesions  of  sufficient  strength  to  wall  off  the  general 
peritoneal  cavity.  The  slight  mechanical  trauma  inflicted  by 
the  insertion  of  sutures  arouses  sufficient  reaction  in  the  apposed 
serous  surfaces  to  ensure  their  adhesion  if  contact  is  maintained  by 
the  sutures  for  a  week  or  ten  days;  hence  such  sutures  always  are 
inserted  in  such  a  manner  as  to  bring  serous  surfaces  into  contact  with 
each  other. 

Peritonitis. — Inflammation  of  the  peritoneum  is  one  of  the  most 
frequent  abdominal  conditions  met  with  in  surgery.  It  is  caused  by 
bacterial  infection.  The  existence  of  "idiopathic"  peritonitis  is  no 
longer  recognized.     Even  if  we  cannot  find  the  portal  of  infection, 

(853) 


854  ABDOMINAL  SURGERY  IN  GENERAL 

we  can  at  least  identify  the  microorganisms  which  are  the  ultimate 
cause  of  the  peritonitis;  and  it  may  be  accepted  as  an  axiomatic  truth 
that  in  practice  no  peritonitis  exists  unless  it  has  been  caused  by 
bacteria.  Experimentally  an  aseptic  peritonitis  may  be  produced  by 
the  intraperitoneal  injection  of  irritating  but  sterile  chemicals;  and 
theoretically  when  any  incision  into  the  peritoneal  cavity  is  repaired 
the  process  of  union  which  occurs  is  a  form  of  peritonitis;  but  what 
is  understood  by  the  term  peritonitis  standing  alone,  is  a  bacterial 
infection  of  the  peritoneum. 

Causes. — The  bacteria  and  their  toxins  gain  access  to  the  peri- 
toneum in  various  ways.  (1)  In  the  immense  majority  of  cases 
they  come  from  the  gastro-intestinal  tract,  which  always  is  swarming 
with  bacteria;  these  escape  from  the  intestinal  tract  as  the  result  of 
lesions  which  will  be  studied  in  the  next  chapter  (appendicitis,  intes- 
tinal obstruction,  cholecystitis,  etc.).  (2)  In  a  large  proportion  of 
cases  in  the  female  the  infection  comes  from  the  internal  genitalia. 
(3)  In  a  few  cases  infection  is  carried  from  without  by  injury;  but  in 
these  cases  the  infection  which  results  from  injury  of  the  intraperi- 
toneal organs  is  much  more  serious  than  that  which  is  carried  into  the 
wound  by  the  vulnerating  body.  (4)  In  a  small  proportion  of  cases 
the  infection  is  believed  to  be  hematogenous  in  origin.  (5)  In  excep- 
tional cases  peritonitis  develops  from  extension  of  inflammation  from 
some  focus  in  kidney,  bladder,  diaphragm,  abdominal  wall,  or  other 
neighboring  structure. 

The  microbes  most  frequently  encountered  are  the  staphylococcus, 
streptococcus,  and  colon  bacillus,  in  enterogenous  infections;  the 
gonococcus  and  streptococcus  in  genital  infections;  and  the  tubercle 
bacillus  or  the  pneumococcus  in  those  apparently  of  hematogenous 
origin. 

Pathology. — As  a  rule,  peritonitis  begins  as  a  more  or  less  localized 
process  in  the  immediate  neighborhood  of  the  atrium  of  infection 
whether  this  be  the  vermiform  appendix,  the  gall-bladder,  the  Fallopian 
tube,  an  ulcer  in  the  gastro-intestinal  tract,  or  any  other  lesion  (Plate 
XIV,  Fig.  1).  Peritonitis  always  is  either  increasing  or  decreasing;  it 
does  not  remain  stationary.  It  is  not  a  state  but  a  process;  it  runs 
a  more  or  less  definite  course,  sometimes  of  infinite  complexity,  owing 
to  changes  wrhich  will  be  studied  in  detail  later.  The  disease  pro- 
gresses either  to  recovery  or  to  death  of  the  patient,  as  surely  as  does 
inflammation  of  any  other  structure  in  the  body,  as  pointed  out  in 
Chapter  I.  Its  course  is  so  very  markedly  influenced  by  treatment 
that  this  important  fact  sometimes  is  overlooked. 

The  omentum  plays  a  much  more  conspicuous  part  in  the  process 
of  peritonitis  than  is  generally  recognized.  This  structure  may  be 
regarded  as  an  aggregation  of  phagocytes  enmeshed  in  fat.  The 
endothelial  cells  which  cover  its  surface  are  highly  phagocytic.  The 
omentum  is  the  chief  source  of  the  reactive  processes  which  are  aroused 
by  peritoneal  infection.  By  chemotactic  attraction  it  is  drawn  to  the 
point  of  attack,  and  it  envelops  the  infecting  lesion  in  the  endeavor 


PERITONITIS  855 

to  localize  it.  Other  adjacent  structures  also  become  adherent  to  each 
other.  When  the  peritonitis  has  been  thus  localized  the  further 
progress  of  the  inflammation  is  the  same  as  that  which  occurs  else- 
where when  the  protective  forces  are  in  the  ascendant :  the  phagocytes 
accomplish  their  task,  the  bacteria  are  killed  and  their  toxins  neutral- 
ized, and  the  patient  recovers  from  his  attack  of  peritonitis.  But 
the  omentum  remains  adherent  to  the  diseased  area;  and  more  or  less 
extensive  intestinal  adhesions  persist.  There  may  or  may  not  be  the 
formation  of  an  abscess  beneath  the  omentum,  or  in  the  midst  of  intes- 
tinal adhesions  (Plate  XIV,  Fig.  3).  If  one  is  formed,  it  will  run  the 
same  pathological  course  as  an  abscess  in  other  situations;  it  will  tend 
to  point  and  to  rupture  at  the  site  of  least  resistance,  and  this  may  be 
into  the  surrounding  peritoneal  cavity,  into  the  bowel,  bladder,  etc., 
or  rarely  through  the  overlying  abdominal  wall.  The  frequency  and 
great  danger  of  intraperitoneal  rupture  makes  it  incumbent  on  the 
surgeon  to  recognize  and  to  drain  such  an  abscess  as  soon  as  possible. 

If  intraperitoneal  rupture  of  such  an  abscess  is  followed  by  a  slight 
attack  of  peritonitis  only,  which  at  once  becomes  localized  in  the  form 
of  a  second  abscess;  and  if  this  abscess  ruptures  in  turn  and  a  third 
abscess  is  formed,  and  so  on  until  multiple  abscesses  exist,  then  the 
condition  corresponds  to  the  progressive  fibrino- purulent  peritonitis  of 
Mikulicz  (1889).  A  large  part  of  the  peritoneal  cavity  may  be  invaded 
in  this  way,  the  intestines,  omentum,  and  neighboring  structures 
being  matted  together  in  an  inextricable  mass  of  adhesions  among 
which  are  found  numerous  minute  abscesses.  This  occurrence  is  rare; 
the  rupture  of  an  abscess  into  the  neighboring  healthy  peritoneal 
cavity  usually  is  attended  by  profound  shock  (toxic  absorption)  and 
often  is  followed  by  death,  no  reaction  occurring  in  the  surrounding 
structures  which  are  overwhelmed. 

If  the  primary  infection  is  very  severe  the  bacterial  toxins  may  be 
diffused  within  the  peritoneal  cavity  before  the  omentum  has  an 
opportunity  to  encapsulate  the  source  of  infection.  Then  you  will 
find  on  opening  the  abdomen  that  the  omentum  appears  to  have 
dissolved  itself  into  an  exudate  which  is  rich  in  anti-bodies  and  which 
on  culture  you  will  often  find  sterile.  The  bacteria  are  enclosed  in 
phagocytes,  or  are  adherent  to  the  omentum,  or  to  the  parietal  or  vis- 
ceral peritoneum.  The  omentum,  as  I  said,  seems  to  be  dissolving  in 
fluid;  it  feels  extremely  slimy,  and  you  cannot  tell  where  omentum 
ceases  and  where  the  fluid  begins;  if  you  hold  the  omentum  up  it  will 
almost  drip  this  fluid  from  its  meshes.  There  are  no  adhesions  any- 
where. Everything  is  covered  by  serous  slime.  This  is  the  stage  of  the 
process  which  is  recognized  as  spreading  or  diffuse  peritonitis  (Plate 
XIV,  Fig.  2).  The  bowels  are  not  much  altered:  those  nearest  the  seat 
of  disease  may  be  red,  their  luster  may  be  slightly  diminished,  and 
they  may  even  feel  a  little  sticky;  but  that  is  all.  The  battle  between 
the  attacking  and  repelling  forces  is  as  yet  undecided;  the  process  is 
very  acute,  and  it  changes  with  alarming  rapidity.  This  change 
may  be  either  for  the  worse  or  the  better.     If  the  latter,  then  the 


856         ABDOMINAL  SURGERY  IN  GENERAL 

anti-bodies  gradually  overcome  the  toxins,  evidences  of  systemic 
poisoning  (toxemia)  subside;  the  peritoneal  exudate  becomes  thicker 
and  more  sticky;  lymph  covers  the  inflamed  intestines  where  their 
endothelial  covering  has  been  destroyed;  frank  pus  begins  to  collect 
in  dependent  situations  and  pockets  of  the  peritoneal  cavity;  and  as 
the  reparative  process  continues  the  infectious  material  is  localized 
in  one  or  many  regions,  which  are  shut  off  from  the  rest  of  the  peri- 
toneal cavity  by  adhesions  between  the  coils  of  intestine,  the  omentum, 
the  parietal  peritoneum,  and  neighboring  structures,  such  as  bladder, 
uterus,  stomach,  gall-bladder,  diaphragm,  etc.  The  result  of  such  an 
attack  of  peritonitis  is  the  formation  of  multiple  residual  abscesses. 
Many  surgeons  confuse  this  condition,  which  is  frequent,  with  that 
described  by  Mikulicz  as  progressive  fibrino-purulent  peritonitis.  The 
pathogenesis  of  the  latter  form  of  peritonitis,  which  is  rare,  has  been 
described  above;  I  believe  the  idea  that  it  is  of  frequent  occurrence 
rests  on  faults  of  observation.  Purulent  exudates  collect,  and  residual 
abscesses  form  chiefly  in  the  dependent  portions  of  the  peritoneal 
cavity,  especially  the  pelvis,  the  iliac  fossa,  the  lumbar  gutters,  or  in 
the  subphrenic  regions  (Plate  XIV,  Fig.  5). 

If  the  resistive  powers  of  the  patient  prove  unequal  to  the  task  of 
localizing  an  attack  of  peritonitis  after  it  has  reached  the  diffuse  stage, 
the  infection  continues  to  spread,  until  what  may  be  called  general 
peritonitis  is  present  (Plate  XIV,  Fig.  4).  From  this  patients  seldom 
recover.  They  die  of  toxemia  or  septicemia  before  the  invading  forces 
have  been  overcome.  And  if  the  virulence  of  the  infecting  organisms 
is  very  high,  or  if  the  patient's  resistance  is  very  much  below  par,  the 
peritoneal  infection  may  spread  with  alarming  rapidity  from  the  very 
first.  In  such  cases  little  or  no  exudate  is  formed,  but,  on  the  con- 
trary, the  bacterial  poisons  are  quickly  absorbed,  and  the  patient  dies 
with  a  dry  peritoneum,  without  adhesions,  without  exudate,  but 
with  the  intestines  red,  friable,  and  on  the  verge  of  disintegration. 
This  usually  is  described  as  septic  peritonitis,  though  the  term  of 
A.  O.  J.  Kelly  (1896),  toxic  peritonitis,  is  preferable.  When  there  is  a 
tendency  for  minute  hemorrhages  to  occur,  either  in  the  subserous 
tissues,  or  free  into  the  peritoneal  cavity,  rendering  the  scanty  exudate 
blood-tinged,  the  condition  is  sometimes  called  hemorrhagic  peritonitis. 

Clinical  Course  and  Diagnosis. — The  symptoms  of  oncoming  peri- 
tonitis are  so  inextricably  bound  up  with  those  of  the  condition  to 
which  it  is  secondary,  such  as  appendicitis,  or  intestinal  perforation, 
that  it  is  difficult  to  distinguish  between  the  two,  especially  as  peri- 
tonitis is  rightly  regarded  not  as  a  distinct  disease,  but  as  itself  a  com- 
plication of  the  underlying  disease.  However,  it  is  convenient  to 
describe  the  clinical  picture  which  a  patient  with  peritonitis  presents 
to  the  observer,  and  then  to  study  more  in  detail  the  physical  signs 
on  which  a  diagnosis  of  peritonitis  is  based. 

Acute  Local  Peritonitis. — The  initial  more  or  less  diffuse  and  colicky 
pain  of  the  primary  lesion  (in  the  appendix,  Fallopian  tube,  gall- 
bladder, etc.)  is  succeeded  within  a  few  hours  by  a  pain  which  is  burn- 


PLATE    XIV 


Peritonitis. 


1.  Acute  local  peritonitis,  from  appendicitis.  2.  Acute  diffuse  peritonitis.  3.  Single, 
primary  abscess.  4.  General  peritonitis.  .5.  Multiple,  residual  abscesses.  (After  de  Quer- 
vain.) 


PERITONITIS  857 

ing,  intense,  and  local.  This  is  increased  by  movement,  by  pressure, 
by  coughing,  or  deep  breathing.  The  affected  area  of  the  abdomen 
becomes  extremely  tender,  the  muscles  overlying  it  are  rigid,  peri- 
stalsis is  arrested  in  the  immediate  vicinity  of  the  lesion,  and  there  is 
local  tympany  due  to  paresis  and  distention  of  the  bowel  most  affected 
by  the  peritonitis.  These  factors  account  for  the  persistent  consti- 
pation, and  the  nausea  and  vomiting.  There  is  moderate  elevation  of 
temperature,  leukocytosis,  and  a  rapid,  hard,  wiry  pulse. 

Acute  Diffuse  Peritonitis. — This  usually  is  a  sequal  to  the  local 
form,  but  in  cases  of  gastric  or  intestinal  perforation  may  exist  from 
the  very  first.  All  the  symptoms  are  aggravated,  and  at  the  onset 
there  often  is  marked  shock.  The  pain  is  almost  unendurable,  con- 
stant, burning,  or  boring,  and  spreads  widely  over  the  abdomen.1 
The  abdomen  is  of  board-like  rigidity  throughout,  and  exquisitely 
tender.  The  patient's  respiration  is  entirely  thoracic,  and  the  flat 
or  even  scaphoid  abdomen  moves  not  at  all,  even  in  deep  inspiration. 
The  patient  lies  on  his  back  or  side,  with  knees  drawn  up  to  relax  the 
abdominal  muscles.  The  constipation  is  absolute;  no  flatus  is  passed; 
peristalsis  is  entirely  absent;  vomiting  is  almost  continuous,  the  patient 
regurgitating  with  little  effort,  every  few  minutes,  small  amounts  of 
offensive  prune-colored  liquid.  The  symptoms  of  this  stage  pass 
almost  imperceptibly  into  those  of  general  peritonitis.  The  evidences 
of  systemic  poisoning  become  pronounced :  there  is  more  fever,  greater 
leukocytosis,  rapid,  shallow  respiration;  the  eye  is  bright,  the  expres- 
sion anxious,  and  the  skin  from  being  rough  and  dry  becomes  covered 
with  a  clammy  moisture.  The  pulse  grows  very  rapid,  running,  weak, 
and  almost  uncountable.  The  abdomen  begins  to  become  distended, 
rigidity  lessens  and  then  disappears;  extreme  distention  finally 
develops.  In  the  last  stages  tenderness  and  leukocytosis  may  be 
absent.  Death  is  preceded  by  delirium,  great  restlessness,  cyanosis, 
air  hunger,  sweating,  subsultus  tendinum,  carphologia,  and  finally 
exhaustion.  In  rare  cases  of  very  severe  infection,  from  the  first, 
and  not  infrequently  before  death,  the  abdomen  is  soft,  and  there  is 
diarrhea  ("septic  diarrhea"). 

The  history  of  the  case  is  of  great  value  in  diagnosing  the  primary 
lesion,  but  in  peritonitis,  as  in  most  other  acute  lesions,  much  more 
reliance  can  be  placed  on  physical  signs  than  on  the  clinical  history  or 
the  symptoms.  It  is  well,  therefore,  to  consider  in  more  detail  some 
of  the  physical  signs  which  were  enumerated  above. 

Rigidity  of.  the  Abdominal  Wall. — This  is  due  to  reflex  (involuntary) 
muscular  contraction,  brought  about  by  stimulation  of  the  spinal 
segments,  whence  arise  both  the  nerves  supplying  the  diseased  abdomi- 
nal viscera  (sympathetic  fibers)  and  those  which  supply  the  over- 
lying muscles  of  the  abdominal  wall.     So  long  as  the  peritonitis  is 

1  Peritonitis  limited  to  the  area  occupied  by  the  small  intestine,  and  confined 
beneath  the  omentum,  may  run  its  course  without  any  of  the  usual  symptoms,  so 
long  as  parietal  peritoneum  is  nowhere  affected;  it  is  only  the  parietal  peritoneum 
which  has  pain  sense,  according  to  Lennander,  while  that  covering  the  viscera  is 
insensitive. 


N.")S         ABDOMINAL  SURGERY  IN  GENERAL 

localized,  the  rigidity  will  remain  local;  spread  of  rigidity  is  an  indica- 
tion that  the  peritonitis  is  spreading  in  a  similar  manner.  In  some 
cases  the  stimulus  seems  to  alfeet  the  sensory  as  well  as  the  motor 
nerve  filaments  of  the  abdominal  wall,  and  hyperesthesia  of  the  skin 
overlying  the  diseased  viseus  is  present.  Conversely,  inexpert  palpa- 
tion of  the  abdominal  wall  with  a  cold  hand,  or  with  fingers  lacking 
in  skill  and  gentleness,  will  stimulate  these  sensory  cutaneous  filaments, 
and  will  cause  contraction  of  the  abdominal  muscles,  and  thus  may 
make  the  careless  examiner  think  that  rigidity  due  to  peritonitis  is 
present,  when  he  has  himself  caused  this  rigidity  by  his  inexpert 
examination.  The  true  reflex  rigidity  of  the  abdominal  muscles  can 
be  recognized  only  by  experience,  and  many  physicians  never  learn 
to  recognize  it,  owing  to  indifference  and  lack  of  practice.  It  is  the 
tactus  eruditus,  the  experienced  touch,  that  counts,  and  the  only  way  to 
gain  this  experience  is  to  palpate  with  attention  and  care  the  abdomens 
of  hundreds  of  patients  with  and  without  peritonitis. 

Palpation  for  muscular  rigidity  should  be  made  with  the  finger 
tips,  but  with  the  utmost  gentleness.  Place  the  tips  of  all  four  fingers 
of  both  hands  very  lightly  on  the  surface  of  the  abdomen  at  some 
point  far  removed  from  the  region  suspected  of  disease  and  palpate 
the  normal  abdominal  wall  first.  Do  this  gently  and  circumspectly 
in  every  case,  and  you  will  gain  your  patient's  confidence,  and  further 
palpation  will  be  easier.  Having  placed  the  fingers  barely  in  contact 
with  the  abdomen,  arrange  them  so  that  alternate  pressure  wTith  each 
hand  will  be  in  a  direction  parallel  to  the  course  of  the  fibers  of  the 
muscle  you  are  about  to  palpate.  Then,  without  at  any  time  raising 
your  fingers  from  the  surface  of  the  abdomen,  and  with  extreme 
gentleness,  bear  down  for  a  fraction  of  a  second  first  with  one  hand 
and  then  with  the  other.  Repeat  this  manipulation  a  number  of 
times  before  passing  to  another  region  of  the  abdomen,  and  accom- 
plish this  transfer  of  your  hands  without  raising  them  from  the  abdomi- 
nal wall,  so  as  to  spare  the  patient  the  shock  of  a  new  contact.  Having 
reached  another  region,  repeat  your  manipulations  here,  and  so  on 
until  the  entire  abdomen  has  been  covered.  This  should  include  the 
rectus  muscle  of  each  side  both  above  and  below  the  umbilicus,  and 
the  oblique  muscles  not  only  in  the  iliac  and  hypogastric  regions, 
but  in  the  flanks  and  in  the  loins  as  well.  In  this  way  you  will  very 
quickly  learn  the  different  sensation  conveyed  to  the  palpating  finger 
by  a  rigid  or  a  normally  relaxed  muscle.  Do  not  be  in  a  hurry,  and 
be  more  gentle  than  you  think  anyone  else  can  be.  •  This  is  not  at 
all  the  same  kind  of  palpation  that  is  desirable  when  one  is  seeking 
to  discover  a  mass  within  the  abdomen.  It  is  this  latter  form  of 
palpation  that  most  physicians  attempt  when  they  seek  for  rigidity, 
with  the  result  that  they  usually  fail  to  recognize  its  presence.  Here 
the  hand  is  laid  flat  on  the  belly,  and  by  gentle  and  rocking  pressure 
alternately  with  the  heel  of  the  hand  and  the  pulps  of  the  fully  extended 
fingers,  the  examiner  seeks  to  depress  the  abdominal  wall  until  the 
underlying  structures  can  be  palpated. 


PERITONITIS  859 

If  rigidity  is  present,  it  is  a  clear  indication  that  some  degree  of 
peritonitis  exists.  Slight  rigidity  usually  indicates  a  mild  grade  of 
peritonitis  so  long  as  the  abdomen  is  not  distended;  and  marked 
rigidity  indicates  peritonitis  of  much  more  serious  import.  So,  too, 
the  extent  of  the  rigidity  on  the  surface  of  the  abdomen  is  a  fair  indi- 
cation of  the  area  of  peritoneum  involved.  But  if  the  patient  is 
excessively  fat,  or  if  the  muscles  are  very  much  atrophied,  no  rigidity 
may  be  palpable. 

Tenderness  on  palpation  is  of  almost  equal  importance  with  rigidity. 
Cutaneous  hyperesthesia,  which  was  referred  to  above,  is  described 
as  superficial  tenderness;  what  is  to  be  studied  now  is  known  as  deep 
tenderness.  When  this  is  exquisite  it  usually  signifies  pus  under  ten- 
sion, whether  the  pus  is  localized  as  an  abscess  or  free  in  the  belly  as 
in  diffuse  peritonitis.  Rigidity  scarcely  ever  is  present  without 
tenderness,  though  the  latter  may  not  be  elicited  by  very  gentle 
palpation  in  the  case  of  a  very  muscular  or  extremely  rigid  abdominal 
wall.  But  tenderness  frequently  persists  after  rigidity  has  given 
way,  as  in  time  it  usually  does,  to  abdominal  distention.  This  per- 
sistence of  tenderness  is  a  very  important  sign,  often  indicating  that 
gangrene  has  occurred  in  the  organ  diseased.  Palpation  through  the 
rectum  often  is  of  great  value,  in  discovering  tenderness  in  the  recto- 
vesical pouch. 

Percussion  of  the  abdominal  wall  should  succeed  palpation.  It 
should  be  done  with  the  utmost  gentleness,  and  not  over  any  area 
which  is  very  tender.  It  is  possible  by  percussion,  much  more  safely 
than  by  palpation,  to  determine  the  presence  of  an  abscess,  or  of  an 
inflammatory  mass  due  to  adherent  omentum.  These  will  give  a 
dull  note  on  percussion,  and  will  be  surrounded  by  areas  of  tympany. 
The  existence  of  an  effusion  which  is  settling  in  the  pelvis  or  the  loins 
may  also  be  ascertained  by  percussion. 

Finally,  auscultation  should  not  be  neglected.  In  cases  of  diffuse 
peritonitis  the  abdomen  is  quiet;  no  peristaltic  sounds  are  heard 
unless  at  a  great  distance  from  the  focus  of  infection. 

Distention  of  the  abdomen  is  a  late  sign  of  peritonitis,  and  of  bad 
prognostic  import.  A  diagnosis  which  is  delayed  until  the  abdomen 
is  distended  is  of  little  use.  The  onset  of  distention  occurs  pari 
passu  with  the  disappearance  of  abdominal  rigidity.  The  distended 
abdomen  may  be  tense  from  tympanites,  but  it  never  is  rigid.  The 
distention  is  the  result  of  two  factors :  the  first  is  paresis  of  the  intes- 
tinal nerves  and  of  those  supplying  the  abdominal  wall,  as  a  result 
of  poisoning  by  the  absorption  of  toxins;  this  relaxes  the  muscular 
tunic  of  the  intestines  and  makes  the  belly  wall  soft.  The  second 
factor  causing  distention  is  the  occurrence  of  fermentative  and  putre- 
factive changes  within  the  intestines,  producing  tympanites.  The 
constipation  which  has  already  been  noted,  and  the  distention  of  the 
abdomen  which  is  here  discussed,  are  the  consequence  and  not  the 
cause  of  the  patient's  illness.  He  is  not  ill  because  his  abdomen  is 
distended,  but  his  abdomen  is  distended  because  he  is  ill. 


860  ABDOMINAL  SURGERY  IN  GENERAL 

Differential  Diagnosis.— Peritonitis  must  be  distinguished  from  the 
colic  of  acute  gastroenteritis,  from  pleurisy  and  pneumonia,  and  from 
intestinal  obstruction.  Other  conditions  with  which  it  is  sometimes 
confounded  will  be  discussed  in  connection  with  the  several  lesions 
which  may  cause  peritonitis. 

Acute  G astro-enteritis. — In  mild  cases  this  is  attended  by  sudden, 
sharp,  stabbing  pain,  which  varies  in  intensity  from  time  to  time — 
intestinal  colic.  The  pain  is  relieved  by  pressure  on  the  abdomen. 
There  is  no  tenderness,  no  rigidity,  no  change  in  pulse  or  tempera- 
ture, and  no  leukocytosis.  Vomiting  is  unusual,  but  if  it  occurs  it  is 
not  repeated  when  the  stomach  has  been  emptied.  In  severer  cases 
there  is  vomiting,  and  general  abdominal  pain  and  tenderness.  There 
may  be  fever,  with  increase  in  the  pulse  rate,  but  there  is  no  rigidity 
of  the  belly  wall;  and  there  is  diarrhea,  which  is  rare  in  peritonitis. 
In  cases  where  doubt  remains  after  a  thorough  examination,  visit  the 
patient  again  after  an  interval  of  three  or  four  hours,  and  keep  him 
in  constant  surveillance  until  the  nature  of  the  disease  is  manifest. 

Pleurisy  and  pneumonia  often  are  attended  by  pain  referred  to  the 
abdomen,  and  in  children  this  may  be  the  only  complaint.  There  is 
no  nausea  or  vomiting;  only  slight  rigidity  of  the  upper  abdomen, 
and  only  superficial  tenderness  (cutaneous  hyperesthesia)  are  present. 
There  is  no  deep  tenderness.  If  the  chest  were  examined  in  all  cases 
of  acute  abdominal  disease,  whether  the  presence  of  pulmonary 
complications  be  suspected  or  not,  the  surgeon  would  be  saved  many 
an  error  and  the  patient  an  unnecessary  operation.  Even  if  the  pul- 
monary lesion  is  so  deep-seated  as  to  give  no  distinct  physical  signs,  a 
diagnosis  of  peritonitis  usually  may  be  excluded  by  the  absence  of 
physical  signs  in  the  abdomen,  and  by  the  presence  of  symptoms,  such 
as  rapid  respiration,  dyspnea,  slight  cyanosis,  etc.,  which  are  charac- 
teristic of  thoracic  disease. 

Intestinal  Obstruction  frequently  is  complicated  by  peritonitis  in 
its  later  stages,  just  as  peritonitis  may  be  followed  at  any  time  by 
intestinal  obstruction.  A  differential  diagnosis  often  is  impossible 
when  either  condition  has  existed  for  some  days,  because  then  both 
conditions  may  be  present.  But  at  the  outset  the  two  affections  pre- 
sent very  different  symptoms  and  physical  signs.  In  intestinal 
obstruction,  attentive  study  of  the  patient's  history  usually  will 
reveal  a  cause  for  the  obstruction  in  some  previous  attack  of  peri- 
tonitis. The  attack  of  intestinal  obstruction  begins  with  colicky  pains, 
and  these  are  more  or  less  relieved  by  pressure  on  the  abdomen. 
The  pain  is  intermittent,  and  between  the  paroxysms  the  patient  may 
feel  quite  comfortable  and  may  appear  very  well.  In  peritonitis  the 
patient  is  decidedly  ill  from  the  very  commencement  of  the  attack, 
and  there  are  no  remissions.  In  obstruction  the  intervals  between 
the  pains  rapidly  shorten,  but  the  pain  does  not  for  a  long  time  become 
constant;  in  peritonitis  it  is  constant  from  the  beginning.  In  obstruc- 
tion there  is  absolute  constipation,  as  in  peritonitis,  and  no  flatus  is 
passed  by  rectum;    vomiting  occurs  early,  is  persistent,  and    soon 


PERITONITIS  861 

becomes  of  the  projectile  type  (p.  937),  with  rather  long  intervals 
between  the  attacks  of  vomiting.  In  peritonitis,  on  the  contrary, 
the  patient  vomits  oftener,  the  vomitus  is  small  in  quantity  each 
time;  and  the  vomiting  is  not  projectile  but  regurgitant  in  type  (p. 
857).  In  obstruction,  as  in  peritonitis,  the  contents  of  the  upper 
bowel  are  vomited  after  the  stomach  has  been  emptied ;  but  in  obstruc- 
tion the  rejected  matters  finally  become  fecal,  which  never  is  the  case 
in  peritonitis.  In  obstruction  there  is  no  rigidity  of  the  abdominal 
wall,  and  distention  occurs  early — often  within  a  few  hours.  Rigidity 
is  the  most  valuable  early  sign  of  peritonitis,  but  distention  seldom 
occurs  until  after  the  lapse  of  eleven  or  twelve  hours.  The  disten- 
tion of  obstruction  may  at  first  be  localized  to  the  area  immediately 
above  the  obstruction.  Auscultation  in  obstruction  detects  extremely 
active  and  disordered  peristalsis;  sometimes  peristaltic  waves  can  be 
clearly  seen  through  the  distended  belly  wall.  In  peritonitis  the 
abdomen  is  silent.  In  obstruction  the  temperature  is  not  elevated, 
while  in  peritonitis  it  almost  always  is  above  normal.  Leukocytosis 
is  rare  in  obstruction,  unless  strangulation  has  occurred;  but  in  peri- 
tonitis it  is  the  rule.  In  both  affections  a  steady  increase  in  the  pulse 
rate  occurs,  and  is  a  most  valuable  sign. 

Treatment. — This  is  not  the  place  to  discuss  the  prevention  of  peri- 
tonitis; but  that  it  may  be  prevented  often  by  prompt  operation 
will  be  pointed  out  time  and  again  in  the  following  pages.  What 
concerns  us  here  is  how  to  treat  the  patient  after  peritonitis  has  devel- 
oped; and  I  here  exclude  from  consideration  pelvic  peritonitis  in 
connection  with  gynecological  affections. 

1.  In  the  early  stages,  before  the  peritoneal  inflammation  has  become 
diffuse,  surgeons  are  in  perfect  accord  in  recommending  immediate 
operation,  to  remove  the  source  of  infection,  and  thus  prevent  the 
development  of  diffuse  peritonitis.  This  is  a  much  surer  and  far 
safer  course  to  pursue  than  to  trust  to  the  unaided  powers  of  nature 
to  isolate  and  overcome  the  infection.  If  the  source  of  infection  is  the 
appendix,  it  can  be  entirely  removed;  if  it  is  a  perforation  of  the 
intestine,  it  can  be  sutured,  and  the  further  discharge  of  infectious 
material  prevented;  if  there  is  a  lesion  which  cannot  be  treated  in 
either  of  these  ways  (as  in  acute  pancreatitis)  the  surgeon  can  at  least 
isolate  the  source  of  infection  by  gauze  packs,  providing  drainage,  and 
thus  preventing  further  intra-abdominal  contamination.  The  details 
of  operation,  which  should  be  completed  quickly,  will  be  described  in 
connection  with  the  various  lesions  which  cause  peritonitis. 

2.  When  the  peritonitis  is  in  the  diffuse  stage  surgeons  are  divided 
into  two  camps.  There  are  those  who  think,  with  Ochsner,  that  it  is 
safer  to  undertake  no  operation  in  cases  of  spreading  peritonitis,  but 
to  trust  to  such  measures  as  are  detailed  below  to  aid  nature  in  isolat- 
ing the  infection,  and  to  wait  until  a  residual  abscess  has  been  formed 
before  instituting  drainage.  Neither  Ochsner  nor  anyone  else,  how- 
ever, ever  claimed  that  the  patient  could  be  cured  without  any  opera- 
tion; the  only  question  is  whether  the  operation  shall  be  immediate 


862  ABDOMINAL  SURGERY   IN  GENERAL 

or  postponed.  Then  there  are  other  surgeons  who  believe,  so  long  as 
the  evidences  of  toxemia  are  not  very  marked,  and  so  long  as  the 
degree  of  abdominal  rigidity  is  greater  than  its  distention,  so  long,  in 
short,  as  it  is  evident  that  the  patient  is  still  reacting  to, the  infection, 
that  throughout  this  period  it  will  be  more  to  the  patient's  ultimate 
advantage  to  institute  drainage  as  soon  as  possible,  and  at  the  same 
time  to  treat  the  focus  of  infection  by  excision,  suture,  or  tamponade, 
provided  this  secondary  part  of  the  operation  can  be  carried  through 
without  unduly  prolonging  the  procedure  or  entailing  too  great 
shock.  My  own  belief  and  my  practice,  founded  on  a  not  very  limited 
experience  with  all  forms  of  peritonitis,  is  that  operation  under  these 
circumstances  is  not  only  justifiable  but  imperative.  Ochsner  and 
others  limit  the  time  within  which  immediate  operation  is  to  be  done 
to  the  first  thirty-six  hours  from  the  beginning  of  the  illness.  No 
doubt  this  is  a  convenient  rule  of  thumb,  but  one  patient  will  reach 
at  the  end  of  twelve  hours  a  stage  of  peritonitis  which  will  not  be 
reached  by  another  for  two  or  three  days.  So  that  I  think  it  is  safer 
to  decide  the  question  in  favor  of  or  against  immediate  operation  not 
on  the  mere  lapse  of  time,  but,  as  I  have  done  above,  on  the  patient's 
physical  condition.  Especially  valuable,  I  believe,  is  the  persistence 
of  rigidity  or  the  onset  of  distention.  Statistics  might  be  quoted  to 
support  the  views  of  surgeons  on  both  sides  of  this  question;  but  the 
fallacy  of  trusting  to  such  figures  is  obvious.  Only  those  who  open 
the  abdomen  in  all  these  cases  know  the  state  of  affairs  inside;  those 
who  do  no  operation  give  statistics  founded  on  impressions,  not  on 
visual  inspection  of  the  peritoneum,  and  they  are  quite  as  likely  to 
reckon  as  non-operative  survivals,  patients  whose  peritonitis  never 
became  widespread,  as  the  really  serious  cases. 

3.  When  diffuse  peritonitis  has  so  far  advanced  that  rigidity  has 
disappeared,  and  marked  distention  is  present,  the  patient  being  very 
toxic  and  perhaps  delirious,  and  constantly  regurgitating  the  upper 
intestinal  contents,  almost  all  surgeons  are  in  agreement  with  Ochsner 
that  operation  is  more  apt  to  hasten  death  than  to  give  the  patient 
a  chance  of  recovery.  In  these  cases,  however,  a  well  defined  course 
of  treatment  must  be  pursued,  and  occasionally  even  a  seemingly 
moribund  patient  will  improve,  one  or  more  abscesses  will  form,  and 
if  these  are  drained  at  a  propitious  time  recovery  may  yet  ensue. 
This  treatment,  about  to  be  described,  is  known  as  the  Ochsner  treat- 
ment of  peritonitis,  because  so  warmly  espoused  by  this  surgeon  ever 
since  1900.  It  should  be  adopted  in  every  case  of  peritonitis  so  soon 
as  the  diagnosis  is  made,  whether  or  not  operation  is  to  be  undertaken. 
If  operation  is  to  be  done,  this  treatment  will  be  of  short  duration, 
but  it  will  aid  materially  in  securing  a  good  result;  and  the  same 
treatment  always  is  continued  after  operation  until  the  peritonitis 
subsides.  The  most  important  features  of  this  non-operative  or 
preparatory  treatment  are:  (1)  abstinence  from  everything  by  mouth 
(hence  it  sometimes  is  called  "starvation  treatment");  (2)  instillation 
of  fluids  by  the  rectum;  and  (3)  the  head  high  position. 


PERITONITIS  863 

The  patient  is  placed  in  bed  either  in  Fowler's  position  (1900), 
lying  flat  on  the  back,  and  with  the  head  of  the  bed  raised  twelve 
to  fifteen  inches  from  the  floor;  or  else  in  the  so-called  exaggerated 
Fowler  position,  that  is,  in  a  semi-sitting  posture  in  the  bed  (Fig.  889) . 
This  aids  the  gravitation  of  fluids  to  the  pelvis  and  keeps  them  away 
from  the  subphrenic  region,  whence  absorption  is  so  rapid,  thus  dimin- 
ishing toxemia;  and  it  lessens  the  chances  of  pulmonary  complications. 
The  patient  is  very  apt  to  slide  down  in  the  bed  unless  supported. 
A  special  chair-like  bed  frame  is  the  best  support,  but  in  emergencies 
a  sand-bag  may  be  passed  beneath  the  mattress  below  the  buttocks, 
or  the  patient  may  sit  in  a  sling  formed  by  tying  the  ends  of  a  sheet 
to  the  two  upper  posts  of  the  bed. 


Fig.  889. — Exaggerated  Fowler  position.  One  week  after  suture  of  a  duodenal  per- 
foration.   Note  slight  elevation  of  reservoir  for  enteroclysis  solution.    Episcopal  Hospital. 

Nothing  whatever  is  given  by  mouth,  not  food,  not  water,  not  ice; 
nothing  is  permitted.  Anything  taken  into  the  stomach  rouses  peris- 
talsis, and  this  spreads  infection  more  widely  in  the  peritoneum. 
Moreover,  it  increases  nausea  and  provokes  vomiting.  The  only  thing 
ever  to  be  introduced  into  the  stomach  is  a  stomach  tube,  which 
should  be  used  every  six  hours  or  less  often,  to  relieve  the  stomach  of 
regurgitated  intestinal  contents.  A  patient  who  has  once  experienced 
the  relief  which  lavage  of  the  stomach  affords  under  these  circum- 
stances is  only  too  anxious  to  have  the  procedure  repeated  as  soon  as 
he  feels  his  stomach  refilling. 

To  replace  the  fluids  lost  by  intraperitoneal  effusion,  the  patient  is 
given  saline  solution  or  tap  water  by  the  rectum,  as  already  described 
in  Chapter  V.  This  does  not  excite  peristalsis,  is  quickly  absorbed, 
allays  thirst,  restores  blood-pressure,  dilutes  circulating  toxins,  and 
after  operation  seems  to  promote  drainage  from  the  wound. 

No  drugs  are  required  as  a  rule.  Stimulants,  such  as  camphorated 
oil,  atropin,  digitalis,  or  strychnin,  seldom  are  indicated  and  do  not 
seem  to  have  much  effect.  Morphin  very  rarely  is  required;  the  pain 
soon  ceases  if  nothing  is  taken  by  mouth  and  if  nausea  is  controlled 
by  lavage.  Unless  there  is  pain,  sleep  is  not  much  interfered  with. 
But  I  do  not  believe  that  morphin  does  any  harm,  and  there  is  no  reason 
why  it  should  not  be  administered  if  it  promotes  the  patient's  comfort. 


8G4  ABDOMINAL  SURGERY  IN  GENERAL 

This  treatment  should  be  continued  until  the  peritonitis  subsides. 
This  period  seldom  is  longer  than  three  days,  but  it  may  be  a  week. 
The  more  absolute  the  treatment  from  the  first,  the  sooner  will  its 
effed  become  manifest.  Under  this  form  of  treatment  many  patients 
who  would  die  under  any  other  form  of  treatment,  or  after  operation, 
will  survive  the  peritonitis,  and  as  the  abdomen  gradually  softens, 
the  surgeon  will  find  evidences  of  one  or  more  collections  of  pus.  Very 
rarely  a  patient  will  recover  from  what  appears  to  have  been  a  diffuse 
septic  peritonitis  without  effusion;  when  the  abdomen  is  opened  later 
to  remove  the  cause  of  the  disease,  few  adhesions  and  no  pus  may  be 
found.  Other  patients  will  die  in  spite  of  this  treatment;  but  it  is 
not  too  much  to  say  that  the  Ochsner  treatment  is  the  only  form  of 
treatment  which  gives  these  bad  cases  of  peritonitis  even  a  fighting 
chance. 

After  the  peritonitis  subsides  the  patient  is  still  far  from  convalescent. 
As  the  abdomen  becomes  softer  auscultation  will  detect  commencing 
peristalsis,  and  it  will  be  painless;  flatus  will  be  passed,  and  the  bowels 
may  move  spontaneously  or  by  simple  enema.  At  this  time  small 
amounts  of  liquid  food  may  be  allowed  by  mouth;  but  if  this 
is  attempted  too  soon  it  will  cause  vomiting,  rouse  active  peristalsis, 
break  up  newly  formed  adhesions,  rupture  an  abscess  which  is  just 
localizing,  and  perhaps  cause  intestinal  obstruction.  The  patient 
must  be  very  carefully  nursed,  and  progress  must  be  sure  rather  than 
rapid.  When  the  abdomen  has  become  entirely  soft  in  parts  removed 
from  the  seat  of  disease,  when  the  bowels  are  acting  normally,  and 
the  patient  is  approaching  convalescence,  then  it  is  time  to  drain  the 
abscesses  which  have  formed.  If  these  are  neglected,  and  intraperi- 
toneal rupture  occurs,  the  patient  seldom  survives  even  immediate 
drainage. 

Residual  Peritoneal  Abscesses.  —  So  long  as  an  intraperitoneal 
abscess  is  present,  the  patient  is  in  constant  danger.  No  delay  should 
be  permitted  in  instituting  drainage  when  once  it  is  ascertained  that 
the  patient  can  withstand  the  intervention.  The  abscess  should  be 
incised  and  drained,  if  possible  without  opening  the  uninvolved 
peritoneal  cavity;  nothing  else  should  be  attempted.  Do  not  make 
any  search  for  the  cause  of  the  peritonitis,  but  be  content  to  secure 
drainage.  Make  sure,  however,  that  you  find  all  the  abscesses.  Plate 
XIV,  Fig.  5,  shows  the  most  frequent  sites  in  which  residual  abscesses 
form.  In  most  cases  a  secondary  and  more  formal  operation  is  indicated 
some  weeks  or  months  later,  to  complete  the  cure  by  removal  of  the 
diseased  organ  (appendix,  gall-bladder),  closure  of  a  fecal  fistula,  etc. 

Pelvic  abscess  sometimes  may  be  drained  by  puncture  through  the 
rectum,  or  through  the  vagina.  Unless  the  anterior  rectal  wall  bulges 
and  fluctuation  is  unmistakable  it  is  safer  usually  to  make  a  supra- 
pubic incision.  This  always  should  be  preferred  whe.i  there  is  also 
an  iliac  abscess;  and  always  after  opening  an  iliac  abscess  the  surgeon 
should  make  sure  that  a  separate  pelvic  abscess  is  not  overlooked. 
A  lumbar  abscess  is  drained  by  an  incision  in  the  flank  or  loin. 


PERITONEAL  ADHESIONS  865 

Subphrenic  abscess  is  of  great  importance,  because,  though  less 
frequent,  it  is  so  often  overlooked.  It  may  occur  either  (1)  to  the  right 
or  (2)  to  the  left  of  the  falciform  ligament  of  the  liver;  or  (3)  behind 
the  right  coronary  ligament;  or  (4)  in  the  lesser  peritoneal  cavity. 
Abscesses  on  the  extraperitoneal  surfaces  are  rare,  and  usually  are 
secondary  to  hepatic  abscess,  in  connection  with  which  they  are  dis- 
cussed (p.  991).  Of  the  four  sites  of  subphrenic  abscess  mentioned 
above,  that  most  frequently  the  seat  of  suppuration  is  the  space 
behind  the  right  coronary  ligament  and  extending  around  its  free 
margin  to  the  subhepatic  space.  Most  abscesses  in  this  situation  are 
secondary  to  appendicitis;  the  abscess  tends  to  point  through  the  lower 
intercostal  spaces,  except  when  intraperitoneal  or  intrapleural  rupture 
occurs.  Most  of  the  abscesses  in  association  with  the  left  lobe  of  the 
liver  in  front  of  the  left  coronary  ligament  are  due  to  gastric  or  duodenal 
lesions;  those  in  the  lesser  peritoneal  cavity  may  follow  gastric  or  pan- 
creatic lesions;  while  those  far  to  the  left  are  rare  and  generally  sec- 
ondary to  splenic  affections  or  are  the  result  of  diffuse  peritonitis. 
The  diagnosis  of  subphrenic  abscess  is  based:  (1)  On  the  history  of  the 
illness,  indicating  a  possible  cause  for  the  formation  of  an  abscess  in 
the  subphrenic  region;  perforated  gastric  or  duodenal  ulcers  cause 
almost  one-third  of  these  cases,  appendicitis  over  one-sixth,  hepatic 
affections  about  one-sixth,  and  the  remaining  one-third  are  due  to 
miscellaneous  affections  (Barnard,  1908).  (2)  On  abdominal  signs  and 
symptoms  of  an  abscess — dulness,  tenderness,  mass,  possibly  rigidity. 
(3)  On  thoracic  signs  and  symptoms,  especially  slight  pleural  frictions 
or  effusion,  or  upward  displacement  of  the  lung  with  increased  dulness 
over  the  liver.  (4)  On  general  signs  and  symptoms  of  suppuration — 
fever,  leukocytosis,  chills  and  sweats,  and  especially  progressive 
emaciation.  X-ray  study  should  not  be  neglected.  In  the  differential 
diagnosis  from  thoracic  affections,  Hoover  (1913)  measures  the  respira- 
tory excursion  at  the  epigastric  angle:  if  the  collection  of  pus  is  sub- 
phrenic, the  excursion  of  the  costal  margin  is  increased  on  the  affected 
side;  while  if  the  pus  is  above  the  diaphragm  and  the  latter  is  depressed 
to  a  straight  line  (not  beyond)  the  respiratory  excursion  is  diminished, 
because  then  the  diaphragm  acts  to  better  mechanical  advan  age 
against  the  intercostal  and  serratus  muscles  which  tend  to  pull  the 
ribs  up  and  out.  The  treatment  of  subphrenic  abscess  involves  drain- 
age by  operation;  nearly  every  patient  not  operated  on  dies.  In  most 
cases  of  right-sided  abscess  the  operation  is  by  thoracotomy,  as  in 
operations  for  abscess  of  the  liver  (p..  992).  Rarely  an  abdominal 
incision  is  proper.    The  general  mortality  is  about  37  per  cent. 

Peritoneal  Adhesions. — This  condition,  which  has  been  referred 
to  (p.  853),  often  is  described  as  chronic  peritonitis;  it  is  rather  the 
result  of  a  former  peritonitis.  There  is  no  inflammatory  process. 
The  adhesions  which  developed  during  the  existence  of  active  inflam- 
mation remain,  and  by  their  interference  with  peristalsis  cause  symp- 
toms of  which  pain  and  obstipation  are  the  most  constant.  The  drag 
of  adherent  structures  on  the  parietal  peritoneum,  the  mesenteries 
55 


866  ABDOMINAL  SURGERY  IN  GENERAL 

or  the  female  genitalia  may  render  life  miserable,  and  the  patient  may 
become  an  invalid.  Purgation  is  apt  to  rouse  such  active  peristalsis 
as  to  increase  pain,  and  sometimes  causes  intestinal  obstruction; 
and  mil  ss  the  bowels  are  opened  normally  the  usual  symptoms  of 
coprostasis  are  present. 

There  are  other  cases  in  which  peritoneal  adhesions  develop  as  the 
result  of  such  an  attenuated  infection  that  the  origin  of  the  affection 
cannot  be  traced.  Such,  it  is  taught  by  some,  are  many  cases  of  Lane's 
kink,  of  Jackson's  membrane,  and  other  forms  of  peritoneal  disease 
which  have  been  recognized  only  within  recent  years,  (p.  951). 

The  surgeon  is  powerless  to  prevent  the  formation  of  adhesions  in 
cases  of  acute  peritonitis,  and,  indeed,  often  hails  them  with  delight 
as  aids  to  the  patient's  immediate  recovery;  but  he  is  careful  when 
he  opens  the  abdomen  in  other  cases  to  avoid  manipulations  which 
will  encourage  the  formation  of  useless  and  disabling  adhesions.  He 
does  not  handle  the  parts  not  concerned  in  the  operation;  he  with- 
draws from  the  abdomen  as  little  of  the  intestine  as  possible,  and 
prevents  it  from  becoming  dried  while  it  is  exposed;  he  uses  only  hot 
moist  gauze  packs  within  the  abdomen,  and  inserts  and  removes  them 
with  gentleness;  and  he  is  careful  to  cover  all  denuded  serous  surfaces 
by  inversion  with  sero-serous  sutures  or  by  stitching  the  omentum 
over  the  defect.  Various  attempts  have  been  made  to  prevent  peri- 
toneal adhesions  by  the  use  of  oily  substances,  but  without  much 
success.  In  laboratory  work,  however,  Saxton  Pope  (1914)  found 
that  a  2  per  cent,  solution  of  sodium  citrate  in  a  3  per  cent,  (hyper- 
tonic) sodium  chloride  solution  possesses  great  power  in  preventing 
peritoneal  adhesions. 

Treatment. — In  the  treatment  of  peritoneal  adhesions,  it  is  only  by 
experience  that  a  surgeon  can  learn  when  to  let  well-enough  alone. 
If  the  adhesions  are  broken  up  the  new  adhesions  that  form  may  be 
still  more  disabling,  in  spite  of  patient  suturing  and  omental  grafting. 
Unless  the  adhesions  produce  symptoms  it  is  better,  as  a  rule,  not  to 
interfere  with  them.  Of  course,  if  intestinal  obstruction  occurs,  this 
must  be  overcome. 

Pneumococcic  Peritonitis. — This  occurs  oftenest  in  children,  par- 
ticularly girls  under  the  age  of  six  years.  Most  cases  are  secondary 
to  a  pneumococcic  infection  of  the  lungs;  but  the  primary  focus  may 
be  situated  elsewhere,  as  in  the  middle  ear  or  the  female  genitalia. 
The  infection  probably  is  more  often  enterogenous  than  hematogenous. 
The  physical  signs  are  those  of  acute  diffuse  peritonitis  (p.  857),  but 
the  patient's  general  condition  is  not  so  much  affected  as  when  the 
peritonitis  is  due  to  the  ordinary  organisms,  and  the  death  rate  is 
much  lower.  In  most  cases  there  is  a  good  deal  of  effusion,  and  this 
usually  becomes  encysted  within  the  course  of  a  few  days  or  a  week. 
It  should  then  be  opened  and  drained. 

Tuberculosis  of  the  Peritoneum. — The  tubercle  bacilli  may  reach 
the  peritoneum  through  the  blood-stream,  from  the  mesenteric  lymph 
nodes,  directly  from  the  intestinal  tract,  or  from  the  Fallopian  tube. 


TUBERCULOSIS  OF   THE  PERITONEUM  867 

In  almost  all  cases  there  are  other  tuberculous  lesions  elsewhere  in 
the  body.  Tuberculosis  of  the  lungs  frequently  preexists,  and  in  a 
large  proportion  of  adult  patients  this  will  develop  later  if  not  already 
present  at  the  time  the  signs  of  peritoneal  tuberculosis  are  noted.  As 
a  complication  of  Pott's  disease  of  the  spine,  tuberculosis  of  the 
peritoneum  is  not  very  rare. 

As  a  part  of  a  general  miliary  tuberculosis  (blood  infection),  tuber- 
culosis of  the  peritoneum  has  no  surgical  interest.  The  cases  of  most 
surgical  importance  are  those  in  which  a  removable  focus  of  tuber- 
culosis exists  in  the  abdominal  cavity.  This  is  most  often  the  Fallo- 
pian tube  in  women,  and  the  vermiform  appendix  in  men.  In  children 
tuberculosis  of  the  mesenteric  lymph  nodes  is  more  frequent.  In  many 
cases  a  tuberculous  ulcer  of  the  small  intestine  is  the  point  of  peritoneal 
infection.  Here,  as  in  the  appendix,  the  tubercle  bacilli  penetrate 
the  thinned  floor  of  the  ulcer,  and  usually  without  a  macroscopical 
perforation,  escape  into  the  peritoneal  cavity,  which  becomes  widely 
covered  with  miliary  tubercles.  These  feel  like  minute  shot  or  sand- 
like particles,  projecting  from  the  serous  surfaces.  They  are  yellowish- 
gray  in  color.  The  same  course  of  events  occurs  when  the  infection 
arises  in  the  Fallopian  tube,  whence  it  may  escape  through  the  abdomi- 
nal ostium,  or  by  a  minute  perforation.  It  is  not  improbable  (Baum- 
gartner)  that  the  lesion  is  not  really  primary  in  the  Fallopian  tube, 
but  that  this  has  been  infected  from  its  peritoneal  surface;  but  at  all 
events,  the  tuberculous  process  is  most  active  here  for  the  time  being, 
presumably  because  the  bacilli  have  found  a  fertile  soil  for  develop- 
ment. Tuberculosis  of  a  hernial  sac  is  not  very  rare.  Usually  it  is 
secondary  to  some  intra-abdominal  focus. 

The  changes  in  the  peritoneum  are  those  characteristic  of  other 
forms  of  peritonitis,  only  very  much  milder  in  degree.  Usually  there 
is  a  moderate  amount  of  exudate  formed.  This  may  be  clear,  yellow- 
ish, greenish,  turbid,  or  even  purulent;  not  seldom  it  is  bloody.  When 
the  disease  has  lasted  for  many  months,  adhesions  form,  and  may  be 
very  extensive,  causing  kinks,  and  leading  to  intestinal  obstruction. 
The  omentum  becomes  thickened  and  forms  lumpy  masses  which 
often  can  be  felt  through  the  abdominal  wall.  As  the  omentum  and 
mesentery  both  may  become  retracted  from  thickening  and  tuberculous 
infiltration,  these  masses  usually  are  situated  in  the  left  hypochon- 
drium.  The  intestines  lie  mostly  below  and  to  the  right,  and  their 
tympanitic  state  adds  to  the  distention  of  the  abdomen.  Among  the 
adherent  intestinal  coils  small  collections  of  puruloid  matter  may  occur. 
Rarely  there  is  a  large  encysted  collection  of  fluid.  Caseous  changes 
in  the  mesenteric  lymph  nodes  are  a  late  occurrence.  The  intestinal 
walls  become  very  friable,  and  internal  (entero-enteric)  fistula  may 
form;  occasionally  an  external  fecal  fistula  develops  spontaneously. 
In  infants  a  tuberculous  abscess  may  discharge  through  the  umbili- 
cus, as  in  a  case  under  my  care  some  years  ago  at  the  Children's 
Hospital. 


868 


ABDOMINAL  SURGERY  IN  GENERAL 


Symptoms  and  Diagnosis. — The  disease  is  one  of  early  adult  life, 
and  of  early  childhood.  Before  five  years  of  age  it  is  not  infrequent. 
It  is  rare  after  thirty-five  or  forty  years.  Most  cases  occur  in  women 
between  eighteen  and  thirty  years  of  age. 

Tuberculous  peritonitis  may  begin  rather  acutely,  or  it  may  be 
chronic  from  the  beginning.  In  the  former  case,  after  a  few  weeks  of 
malaise  and  gastrointestinal  derangements  (colics,  attacks  of  con- 
stipation and  diarrhea,  nausea)  the  first  thing  to  attract  the  patient's 
attention  is  enlargement  of  the  abdomen,  due  to  serous  effusion. 
This  may  persist  unchanged  for  months,  but  usually  there  are  times 
when  the  abdomen  seems  to  become  smaller.  As  time  goes  on,  adhe- 
sions begin  to  form,  and  if  spontaneous  recovery  takes  place  (and  it 
is  not  unknown)  the  abdomen  becomes  softer,  the  bowels  act  normally, 
the  general  health  improves,  and  the  patient  convalesces.  Or  an 
encysted  collection  of  fluid  may  form,  and  be  cured  by  evacuation. 

In  cases  which  are  chronic  from  the  beginning  the  prodromal 
symptoms  may  have  existed  for  many  months;  there  rarely  is  much 
effusion;  often  none  can  be  detected.  Omental  masses  may  be 
palpable,  and  they  may  change  their  site  and  their  form  from  time 
to  time,  in  the  course  of  weeks  or  months,  from  no  appreciable  cause. 
Usually  the  subjective  symptoms  are  slight,  unless  the  adhesions 
cause  intestinal  obstruction,  or  secondary  infection  produces  hectic 
fever.  So  long  as  the  patients  lie  quiet  in  bed  and  are  carefully  nursed 
little  change  in  their  condition  may  be  appreciable  from  month  to 
month  (Fig.  890). 


Fig.  890. — Tuberculosis  of  the  peritoneum  with  effusion.     Episcopal  Hospital. 


The  diagnosis  of  peritoneal  tuberculosis  will  be  strengthened  by 
finding  any  tuberculous  focus  elsewhere  in  the  body.  Tuberculosis 
of  the  bones  usually  will  be  easily  detected;  but  examination  should 
also  be  made  of  the  lungs,  testicles,  prostate,  seminal  vesicles,  and 
kidneys,  as  incipient  lesions  in  these  structures  often  are  overlooked. 

Treatment. — The  general  hygienic  treatment  already  recommended 
(p.  80)  for  patients  with  tuberculosis  is  most  important  in  cases  of 
tuberculous  peritonitis.  A  fair  proportion  of  cases,  as  pointed  out  by 
Fenger  (1901),  tend  toward  spontaneous  recovery.  If  improvement 
under  general  hygienic  treatment  is  progressive,  no  operation  is  indi- 
cated. In  other  cases,  however,  effusion  persists;  the  patient  does  not 
gain  ground,  and  may  grow  progressively  worse.     In  these  patients, 


OPERATIONS  ON  THE  ABDOMEN  869 

the  propriety  of  operative  interference  must  be  considered.  Operation 
has  been  found,  empirically,  to  be  of  most  value  in  cases  with  effusion. 
Tapping  and  aspiration  of  the  fluid  never  have  produced  as  good 
results  as  formal  incision  and  evacuation.  Probably  this  is  for  the 
same  reasons  that  incision  and  evacuation  of  cold  abscesses  in  con- 
nection with  joint  tuberculosis  are  more  successful  than  is  aspiration; 
the  peritoneal  effusion  of  tuberculosis  is  similar  to  a  cold  abscess 
elsewhere,  and  it  is  important  to  prevent  the  occurrence  of  secondary 
infection,  either  from  the  surface  of  the  body  or  from  within  the 
intestinal  tract.  The  abdomen  should  be  opened  in  women,  as  if  for 
an  operation  on  the  uterine  appendages;  in  men,  over  the  appendicular 
region;  as  these  are  the  most  frequent  sites  of  primary  foci.  When- 
ever possible,  without  inflicting  damage  on  the  intestines,  a  tuber- 
culous appendix  in  men  should  be  removed ;  in  women  not  only  should 
one  or  both  tubes  be  removed  if  affected,  but  a  diseased  appendix 
also.  If  adhesions  are  present  the  utmost  caution  should  be  used  if 
any  attempts  to  separate  them  are  made.  It  is  very  easy  to  tear  a 
hole  in  the  intestine,  and  very  difficult  to  repair  it.  Even  if  the  intes- 
tinal sutures  can  be  made  to  hold,  union  very  seldom  occurs,  and  a 
fecal  fistula  is  the  nearly  inevitable  result.  Only  if  the  bowel  has  been 
torn  should  the  abdomen  be  drained.  In  other  cases  it  should  be 
closed  tightly,  to  prevent  any  possibility  of  secondary  infection  from 
the  surface  of  the  body. 

In  general  it  may  be  said  that  the  immediate  mortality  following 
operation  is  very  small,  if  proper  precautions  are  taken  against  injuring 
the  intestines.  The  ultimate  prognosis  is  better  when  some  focus  such 
as  the  appendix  or  tube  has  been  removed.  Cure  occurs  much  oftener 
in  the  ascitic  than  in  the  dry  cases.  If  the  patients  are  traced,  nearly 
half  the  number  will  be  found  to  die  within  a  few  years,  and  there 
will  be  many  recurrences.  But  the  prognosis  is  better  with  than  with- 
out operation,  and  even  a  few  years  of  comparative  freedom  from 
discomfort  are  not  to  be  despised. 


OPERATIONS  ON  THE  ABDOMEN. 

Laparotomy,  or  Abdominal  Section,  is  a  general  term  used  to 
describe  any  operation  which  involves  opening  the  peritoneal  cavity.1 
Definite  operations  are  described  more  accurately  by  specific  names, 
such  as  gastro-enterostomy ,  cholecystectomy,  entero-anastomosis,  etc. 
These  terms  will  be  defined  in  the  proper  place.  They  are  sufficiently 
descriptive  of  the  operation  when  they  stand  alone,  and  it  is  not 
necessary  to  complicate  them  by  the  prefix  laparo-  as  is  done  by  some 
surgeons ;  though  all  such  operations  include  that  of  laparotomy. 

1  Laparotomy  is  derived  from  hanapa  the  Greek  word  for  the  soft  parts  between 
the  ribs  and  pelvis.  Celiotomy  is  used  as  an  equivalent  by  some  writers,  but  is 
considered  less  correct,  as  the  Greek  term  itoiTda  from  which  it  is  derived  was 
used  for  a  cavity  of  any  kind— a  joint,  the  heart,  as  well  as  the  abdomen. 


870  ABDOMINAL  SURGERY  IN  GENERAL 

Abdominal  Incisions.  In  planning  an  incision  through  the  abdomi- 
nal wall,  the  surgeon  must  have  in  mind  not  only  ready  and  sufficient 
exposure  of  the  abdominal  viscera  concerned  in  the  operation,  but  also 
must  endeavor  to  inflict  as  little  injury  as  possible  on  the  structures 
through  which  he  cuts.  There  are  three  things  to  be  considered  in 
this  connection — the  bloodvessels,  the  muscles  with  their  aponeuroses, 
and  the  motor  nerves. 

The  bhodsupply  is  so  free  that  injury  or  ligation  of  any  one  of  the 
main  arterial  trunks  entails  no  danger  of  sloughing;  but  such  injury 
should  be  avoided  whenever  possible  because  time  is  lost  in  checking 
the  hemorrhage,  and  the  wround  is  more  liable  to  become  infected  if 
not  kept  dry  during  the  operation  and  if  deprived  of  proper  blood 
supply  while  healing.  The  deep  epigastric  artery  is  the  most  impor- 
tant; the  superior  epigastric  is  much  smaller;  and  the  deep  circumflex 
iliac  is  not  often  encountered. 

Muscles  should  be  split  in  the  course  of  their  fibers  whenever  possible. 
Transverse  section  of  muscle  fibers  is  to  be  avoided;  when  this  is 
unavoidable,  the  muscle  must  be  repaired  by  suture.  The  resulting 
cicatrix  in  the  muscle  will  resemble  one  of  the  linese  transversa?  in  the 
rectus  abdominis  muscle;  this  will  not  impair  much  the  muscle's  con- 
tractility, but  it  complicates  the  operation  and  is  undesirable.  The 
fibers  of  the  three  oblique  muscles  of  the  abdomen  cross  each  other's 
course  at  various  angles,  and  transverse  division  of  one  or  two  of  these 
muscles  can  be  avoided  only  in  small  incisions,  such  as  the  gridiron 
incision  of  McBurney  (p.  872),  where  each  muscular  layer  is  split 
in  the  direction  of  its  fibers.  Incisions  through  the  rectus  muscle 
can  be  made  of  any  length  by  splitting  its  fibers  parallel  to  their 
course.  An  incision  through  muscular  tissue  is  preferable  to  one 
through  the  linea  alba  or  the  linea  semilunaris,  because  where  several 
layers  of  tissue  are  traversed,  as  in  cutting  through  a  muscle  and  its 
sheath,  much  firmer  union  can  be  secured  by  suturing  the  wound  in 
several  layers,  than  where  only  one  aponeurotic  structure  is  avail- 
able. 

The  motor  nerves  are  the  most  important  of  all  structures  to  preserve, 
since  they  are  so  small  that  they  cannot  be  sutured  if  cut,  and  the 
muscles  supplied  by  them  are  paralyzed,  and  permit  marked  bulging 
of  the  abdominal  wall  in  spite  of  accurate  repair  of  muscular  and 
aponeurotic  structures  by  suture.  These  nerves  are  branches  of  the 
lower  intercostals  (6th  to  12th)  and  they  run  more  or  less  transversely 
forward  from  the  intercostal  spaces  between  the  transversalis  and 
internal  oblique  muscles,  giving  off  branches  to  these  and  the  external 
oblique;  finally  they  perforate  the  posterior  sheath  of  the  rectus 
muscle  and  supply  it  by  numerous  fine  twigs.  Any  incision  which  will 
divide  these  nerves  is  to  be  avoided  whenever  possible.  An  incision 
through  the  semilunar  line  will  cut  the  nerves  supplying  that  portion 
of  the  rectus  muscle  between  the  incision  and  the  linea  alba.  Hence 
any  longitudinal  incision,  unless  quite  short,  should  be  made  as  near 
the  linea  alba  as  possible.     If  an  incision  is  planned  for  any  other 


OPERATIONS  ON  THE  ABDOMEN 


871 


part  of  the  abdominal  wall,  it  should,  so  far  as  possible,  run  parallel  to 
and  between  two  of  the  motor  nerves. 

Section  of  nerves,  as  mentioned  above,  results  in  bulging  of  the 
abdominal  wall  from  muscular  paralysis  (Fig.  891).  This  may  entail 
great  disability;  and  unlike  incisional  hernia  (p.  824),  with  which  it 
should  not  be  confused,  it  cannot  be  cured  by  operation.  All  that  can 
be  done  is  to  apply  some  form  of  abdominal  support,  as  in  cases  of 
pendulous  abdomen  (p.  953). 

For  operations  on  the  stomach,  intestines,  and  female  generative 
organs  surgeons  usually  employ  a  longitudinal  incision  splitting  the 
fibers  of  the  rectus  muscle  close  to  the  linea  alba  on  the  right  or  left, 


»        i 

I 

* 

• 

Fig.  891. — Bulging  of  right  side  of 
abdomen    from    paralysis  of    motor 
nerves  as  result  of  long  incision  in  right] 
rectus  muscle.     Episcopal  Hospital. 


Fig.  892. — Incision   for    perforated    duo- 
denal   ulcer.      Cicatrix   8  cm.  long.     Supra- 
lj  A  pubic  stab  wound  for  drainage.     Episcopal 
Hospital. 


whichever  appears  to  give  readiest  access  to  the  seat  of  disease.  An 
epigastric  incision  of  course  is  used  in  stomach  operations  (Fig.  892), 
and  one  in  the  hypogastrium  for  pelvic  operations.  For  operations 
on  the  small  intestines  the  incision  usually  is  made  to  the  left  of  the 
median  line,  just  below  the  umbilicus;  thus  it  may  be  extended  upward 
past  the  umbilicus  without  injuring  the  round  ligament  of  the  liver, 
which  lies  to  the  right. 

For  operations  on  the  gall-bladder  the  usual  incision  is  a  longitudinal 
one  through  the  outer  third  of  the  right  rectus  muscle,  from  the  costal 
margin  downward  for  four  inches;  if  more  room  is  needed  the  incision 
is  extended  obliquely  upward  along  the  costal  border  to  the  ensiform 
process    (Mayo  Robson's  incision)    (Fig.  982).     Though  this  incision 


872  ABDOMINAL  SURGERY  IN  GENERAL 

necessarily  divides  a  number  of  motor  nerves  the  resulting  disability 
is  much  less  than  when  an  incision  of  similar  length  is  used  in  the 
lower  abdomen,  where  the  tension  is  greater. 

For  operations  on  the  appendix  a  lateral  incision  is  employed.  If 
only  a  small  incision  is  required,  the  muscle-splitting  or  gridiron  incision, 
introduced  in  1893  by  McBurney,  is  preferred  by  many  operators.1  It 
is  centered  over  McBurney 's  point,  which  is  "from  one  and  a  half  to 
two  inches"  (about  4  cm.)  from  the  right  anterior  superior  iliac  spine,  and 
on  a  line  from  that  point  to  the  umbilicus.  The  skin  incision  is  made 
parallel  to  Poupart's  ligament,  and  the  aponeurosis  of  the  external 
oblique  is  divided  in  the  same  direction,  parallel  to  its  fibers.  The 
fibers  of  the  internal  oblique  are  thus  exposed.  They  run  nearly  at 
right  angles  with  the  previous  incision,  and  are  split  in  this  direction. 
The  fibers  of  the  transversalis  at  this  point  run  in  the  same  direction 
as  those  of  the  internal  oblique,  and  are  split  with  them  in  the  direc- 
tion of  their  course.  The  peritoneum  is  opened  by  an  incision 
parallel  to  that  through  the  skin.  This  gridiron  incision  cannot 
well  be  made  more  than  8  to  10  cm.  long.  Many  surgeons  expose 
the  appendix  by  a  longitudinal  incision  splitting  the  outer  fibers 
of  the  right  rectus  muscle;  this  has  been  called  Deavers  incision; 
he  calls  it  the  "simple  incision."  Or,  after  opening  the  anterior  sheath 
of  the  rectus  and  displacing  the  fibers  of  this  muscle  toward  the  median 
line  (passing  around  the  lateral  border  of  the  muscle  without  splitting 
its  fibers),  the  posterior  sheath  of  the  rectus,  together  with  the  trans- 
versalis fascia  and  peritoneum,  may  be  incised,  as  proposed  by  Battle 
in  1895,  by  Jalaguier  and  by  Kammerer  in  1897,  and  by  Lennander  in 
1898.  Both  this  and  Deaver's  incision  necessarily  divide  a  number 
of  nerves  to  the  rectus  muscle  unless  the  incision  is  short.  For  this 
reason  I  prefer  the  transverse  incision  of  G.  G.  Davis  (1906),  which 
is  described  at  p.  906. 

Making  the  Abdominal  Incision. — The  skin  and  superficial  fascia  are 
divided  down  to  the  aponeurotic  layer  (external  oblique  aponeurosis, 
anterior  sheath  of  rectus).  Bleeding-points  are  clamped.  The  aponeu- 
rotic layer  is  then  divided  throughout  the  length  of  the  incision.  Do 
not  forget  that  in  the  lower  abdominal  wall  the  aponeurosis  of  the 
external  oblique  does  not  blend  with  the  rectus  sheath  at  the  semilunar 
line,  but  passes  as  a  separate  structure  for  some  distance  toward  the 
median  line  before  blending.  Therefore  an  incision  in  the  lower  abdo- 
men just  to  the  median  side  of  the  semilunar  line  must  divide  the  exter- 
nal oblique  aponeurosis  and  the  rectus  sheath  as  separate  structures 
before  the  muscular  fibers  of  the  rectus  will  be  exposed.  When  the 
muscular  fibers  are  exposed  they  are  to  be  split  parallel  to  their  course. 
This  is  best  done  by  the  handle  of  the  scalpel,  followed  by  the  fingers 
of  the  surgeon.  In  the  hypogastric  region  the  rectus  fibers  should  be 
split  from  below  upward,  and  in  the  epigastric  region  from  above 
downward,  so  as  in  each  case  to  brush  aside  rather  than  break  off  the 

1  It  had  been  used  previously  by  L.  L.  McArthur. 


OPERATIONS  ON  THE  ABDOMEN 


873 


branches  of  the  epigastric  arteries  which  run  in  the  directions  named — 
from  the  epigastrium  down,  and  from  the  hypogastrium  up.  When  the 
transversalis  fascia  and  peritoneum  are  exposed  they  should  be  caught 
up  in  two  forceps,  applied  about  a  centimeter  apart,  and  should 
be  drawn  away  from  the  underlying  viscera;  then  the  surgeon  should 
divide  these  structures  cautiously,  with  the  flat  (not  the  point)  of  the 
knife,  held  sideways  (Fig.  893) .  If  the  peritoneal  cavity  is  not  opened 
at  once,  another  hold  should  be  taken  of  the  intervening  tissues,  and 
thus  the  surgeon  should  cut  down  layer  by  layer  until  the  peritoneum 
has  been  opened.  As  soon  as  this  is  accomplished,  the  scalpel  is  laid 
aside,  and  the  peritoneal  opening  is  enlarged  by  a  blunt  pointed 
scissors  passed  on  the  finger  as  a  guide.  The  peritoneum  is  opened 
to  the  full  length  of  the  abdominal  wound. 


Fig.  893.— Incising  the  parietal 
peritoneum. 


Fig.  894. — Suturing   parietal  peritoneum 
(Deaver  and  Ashhurst.) 


Closing  the  Abdominal  Incision.— The  cut  margins  of  the  peritoneum 
(including  the  transversalis  fascia,  and  where  present  the  posterior 
sheath  of  the  rectus)  are  caught  in  hemostats,  and  drawn  into  the 
wound  until  visible.  The  abdominal  viscera  are  kept  from  protruding 
by  the  insertion  of  a  gauze  pack.  Then  the  peritoneum  is  closed  with 
a  continuous  catgut  suture,  applied  so  as  to  evert  the  peritoneum  into 
the  wound  (Fig.  894).  This  brings  endothelial  surfaces  together, 
favors  rapid  union,  and  lessens  the  chances  of  omentum  becoming 
adherent  to  the  abdominal  surface  of  the  cicatrix.  Before  the  last 
peritoneal  suture  is  drawn  tight,  the  gauze  pack  is  removed. 


S7I 


BDOMINAL  SURGERY  tN  GENERAL 


If  the  wound  is  large  or  if  the  patient  is  very  fat,  several  "relaxa- 
tion" or  "splint  sutures"  are  next  inserted;  these  are  interrupted 
sutures  of  non-absorbable  material,  silkworm  gut,  linen,  or  wire. 
Each  splint  suture  is  passed  from  the  skin  surfaee  down  through  all 
structures  of  the  abdominal  wall  to  the  peritoneum  (which  has  already 
been  sutured)  across  the  wound,  and  out  through  all  structures  of  the 
abdominal  wall  on  the  other  side,  to  the  skin  surface.  None  of  these 
sutures  is  tied  at  this  time. 


Fig.  895.— The  "splint  sutures"  have  been  inserted,  and  their  ends  are  clamped, 
anterior  sheath  of  the  rectus  is  being  sutured.      (Deaver  and  Ashhurst.) 


The 


Next  the  aponeurotic  layer  is  sutured  with  a  continuous  stitch  of 
chromic  catgut  (Fig.  895).  The  split  muscle  fibers  fall  together  naturally 
and  do  not  require  a  separate  suture.  If  there  is  much  subcutaneous  fat, 
a  continuous  suture  of  plain  catgut  may  be  used  to  appose  it.  Finally 
the  splint  sutures  are  pulled  taut  and  tied,  not  with  very  much  tension, 
but  just  tight  enough  to  obliterate  all  dead  spaces  in  the  wound.  A 
few  superficial  skin  sutures  may  be  required  to  secure  accurate  closure. 
If  the  patient  is  not  fat,  and  the  wound  small,  the  splint  sutures  may 
be  omitted. 

In  wounds  which  may  become  septic  (many  drained  wounds)  it  is 
safer  to  use  interrupted  sutures  throughout,  so  that  should  one  stitch 
become  infected  it  may  be  removed  without  destroying  the  entire 
row  of  sutures. 

General  Technique  of  Abdominal  Operations. — There  are  so  many 
technical  points  that  are  common  to  different  abdominal  operations, 


OPERATIONS  ON  THE  ABDOMEN  875 

that  it  is  convenient  to  describe  them  together.  I  shall  consider  here 
preparation  for  operation,  and  after  care;  as  well  as  intestinal  localization, 
methods  of  intestinal  suture,  intestinal  resection,  and  entero-anastomosis. 

In  all  abdominal  operations  the  parts  especially  concerned  in  the 
manipulations  are  walled  off  from  the  rest  of  the  viscera  by  gauze 
"packs"  or  "pads."  These  are  made  by  stitching  together  a  number 
of  layers  of  gauze  (four  to  six  thicknesses  is  sufficient)  so  as  to  give 
the  packs  a  certain  bulk,  and  prevent  ravellings  from  escaping  into 
the  wound.  These  packs  are  made  of  convenient  sizes;  for  a  major 
laparotomy,  they  should  be  about  20  by  35  cm.;  for  a  minor  lapa- 
rotomy they  may  be  much  smaller.  Most  important  is  it  not  to  allow 
one  of  the  gauze  packs,  or  a  sponge,  or  an  instrument,  to  become  lost 
in  the  wound.  Such  accidents  sometimes  occur,  but  with  care  and 
system  are  avoidable  in  almost  all  cases.  It  is  best  to  have  a  tape 
attached  to  one  corner  of  each  pack,  and  to  leave  this  tape  hanging  out 
of  the  wound,  clamped  by  a  hemostat;  if  a  piece  of  gauze  never  is  placed 
entirely  within  the  abdomen,  it  is  not  likely  that  it  will  slip  in  unper- 
ceived.  Some  operators  employ  a  continuous  roll  of  gauze,  which  is 
unrolled  only  as  it  is  inserted  into  the  abdomen.  These  packs,  and 
all  gauze  employed  within  the  abdomen,  should  be  used  only  after 
they  have  been  moistened  in  hot  saline  solution. 

Preparation  of  Patient  for  Abdominal  Operation. — Unless  immediate 
operation  is  demanded,  as  in  emergency  cases,  the  preparation  of  the 
patient  should  begin  at  least  twenty-four  hours  before  the  time  set 
for  the  operation.  It  is  well  that  he  should  learn  to  pass  his  urine 
while  lying  on  the  flat  of  his  back  (Atlee);  it  may  save  him  much  dis- 
comfort after  operation.  Other  general  preparation  is  the  same  as 
for  any  major  operation.  The  intestinal  tract  should  be  well  cleared 
by  a  purge  and  this  should  be  administered  sufficiently  early  on  the 
day  before  the  operation  for  it  to  act  before  night,  so  that  the  patient's 
sleep  may  not  be  disturbed.  On  the  day  of  operation,  and  at  least 
two  hours  before  the  time  set  for  operation,  the  patient  should  be 
given  an  enema  of  warm  soapsuds.  Even  in  emergency  cases  it  often 
is  well  to  administer  an  enema  just  before  operation. 

The  abdomen  should  be  shaved,  including  the  pubic  hair,  and 
should  be  washed  with  green  soap,  rubbed  with  alcohol  (60  per 
cent.),  and  covered  with  a  dry  sterile  dressing.  This  preparation 
is  best  done  in  the  evening  of  the  day  before  operation;  unless  done 
at  least  three  or  four  hours  before  operation,  the  skin  will  not  be 
sufficiently  dry  at  the  time  of  operation  for  the  use  of  iodin  to  be 
effectual  (p.  143).  If  iodin  is  not  used,  the  entire  abdomen  should 
be  washed  again,  after  the  patient  is  etherized,  as  at  the  first  prepa- 
ration. In  emergencies  it  is  sufficient  to  paint  the  abdomen  (pre- 
viously shaved  dry)  with  3  per  cent,  iodin  twice,  allowing  the  first 
coat  of  iodin  solution  to  become  thoroughly  dried  before  the  second 
is  applied  and  waiting  until  the  second  has  dried  before  making  the 
incision.     A  2  per  cent,  solution  of  picric  acid  is  as  good  as  iodin. 

On  the  evening  before  operation  the  patient  should  eat  only  a 


87G  ABDOMINAL  SURGERY  IN  GENERAL 

light,  semi-solid  meal.  Only  cooked  (sterile)  food  should  be  taken  for 
at  least  two  days  before  operation.  The  mouth  and  teeth  should  be 
carefully  cleansed.  On  the  day  of  operation  nothing  but  water  should 
be  allowed,  unless  the  operation  is  to  be  late  in  the  afternoon.  Then 
a  little  liquid,  preferably  not  milk,  should  be  given  for  breakfast. 
Water  may  be  taken  until  two  hours  before  operation,  but  not  in 
excessive  quantities. 


Fig.  896. — Gauze  packs,  for  a  major  laparotomy;  with  "sponge  forceps." 

After-treatment  in  Abdominal  Operations. — Very  little  except  careful 
nursing  is  required  in  uncomplicated  cases.  Immediately  after  opera- 
tion, before  recovery  from  the  anesthetic,  a  liter  of  hot  water  should 
be  injected  into  the  rectum  and  allowed  to  remain.  If  there  is  no 
vomiting,  5  c.c.  of  hot  water  (not  luke-warm)  may  be  given  every  few 
minutes  after  eight  to  twelve  hours.  I  am  quite  convinced  that 
really  hot  water  is  less  apt  to  cause  nausea  than  is  ice  or  ice-water. 
After  eighteen  to  twenty-four  hours  small  quantities  of  liquid  diet 
may  be  given;  soft  diet  may  be  begun  on  the  third  or  fourth  day. 
If  the  stomach  has  been  the  seat  of  operation  mouth-feeding  should 
not  be  begun  for  from  twenty-four  to  thirty-six  hours  after  operation. 
Vomiting  is  treated  by  total  abstinence  from  mouth-feeding;  by 
sitting  the  patient  up  in  bed;  by  the  administration  of  a  glass  of  hot 
water;  and  finally  by  lavage.  The  treatment  of  peritonitis  has  already 
been  considered  (p.  861). 

The  surgeon  should  not  be  in  too  great  a  hurry  to  have  the  patient's 
bowels  moved.  Unless  they  move  spontaneously,  an  enema  may  be 
given  on  the  third  or  fourth  day.    Owing  to  the  pre-operative  catharsis, 


OPERATIONS  ON  THE  ABDOMEN  877 

and  the  abstinence  from  food  after  operation,  it  is  futile  to  expect  a 
free  evacuation  any  sooner.  Cathartics  should  not  be  given  after 
operation  unless  the  enema  proves  ineffectual.  Calomel  in  divided 
doses,  followed  by  a  saline  purge,  usually  is  preferred. 

The  patient  may  be  turned  on  his  side  (this  does  not  mean  that  he 
may  turn  himself)  on  the  second  day  after  operation  if  he  desires  it. 
He  should  be  made  comfortable.  If  there  is  peritonitis  he  will  be  in 
the  sitting  posture  (Fig.  889)  and  will  not  need  to  be  turned  over  to 
ease  his  back. 

It  is  not  well  for  the  patient  to  leave  bed  until  several  days  after 
the  sutures  have  been  removed.  Rarely  should  an  abdominal  patient 
spend  less  than  two  weeks  in  bed.  If  the  incision  was  large,  or  the 
operation  very  extensive,  it  may  be  advisable  for  the  patient  to  remain 
in  bed  three  weeks  or  longer.  Only  the  very  old  should  be  hurried 
out  of  bed ;  and  even  they,  if  they  can  be  made  comfortable  in  a  sitting 
position  in  bed,  do  just  as  well  in  bed  as  in  a  chair. 

Intestinal  Localization. — Often  during  the  course  of  an  abdominal 
operation  it  becomes  important  to  distinguish  large  from  small  bowel, 
or  even  to  identify  more  or  less  accurately  different  areas  of  the  latter 
as  belonging  to  the  upper  jejunum,  the  middle  of  the  small  gut,  or 
the  lower  ileum.  In  cases  of  peritonitis  or  intestinal  obstruction,  the 
small  intestine  may  be  so  distended  as  to  equal  or  exceed  the  size  of 
the  colon,  so  that  mere  size  is  no  criterion.  In  many  cases  the  longi- 
tudinal bands  on  the  colon  may  be  recognized,  or  even  the  sacculation 
of  the  large  intestine;  but  inflammatory  changes  or  distention  may 
obscure  such  means  of  identification.  The  large  intestine  in  fat  adults 
is  covered  by  epiploic  appendages;  but  in  children  and  emaciated 
adults  these  are  absent.  The  safest  and  most  constant  distinction  is 
the  attachment  of  the  intestine  to  the  posterior  abdominal  wall  by 
its  mesenteries  (Da  Costa,  1894).  The  small  intestine  is  attached 
by  its  mesentery  obliquely  across  the  lumbar  spine:  the  coils  of  small 
bowel  rarely  can  be  brought  very  far  laterally  in  the  abdominal  cavity, 
but  usually  occupy  its  middle  portion.  The  large  intestine  is  attached 
to  the  posterior  abdominal  wall  on  the  right  and  left  of  the  abdomen, 
and  transversely  above.  If  all  the  intra-abdominal  structures  are 
pushed  away  from  the  right  side  by  the  use  of  gauze  pads,  the  bowel 
which  it  will  be  impossible  to  push  away,  will  be  the  cecum  and  ascend- 
ing colon.  In  inserting  the  hand,  if  the  fingers  be  made  to  follow  the 
peritoneum  on  the  right  across  the  flank,  into  the  loin,  and  toward 
the  median  line,  the  first  bowel  they  encounter  attached  to  the  pos- 
terior abdominal  wall,  will  be  the  ascending  colon.  The  same  con- 
dition of  affairs  exists  on  the  left  side :  the  descending  colon  and  the 
sigmoid  have  their  posterior  attachments  further  to  the  left  than  any 
of  the  intestines,  and  after  all  the  movable  bowels  have  been  packed 
away  from  the  left  side,  the  immovable  intestine,  which  remains 
relatively  fixed,  will  be  the  descending  colon  or  sigmoid.  The  sigmoid 
often  has  a  long  mesentery,  and  the  sigmoid  loop  may  prolapse  into  a 
right  inguinal  incision.     The  same  is  true  of  the  transverse  colon, 


878  ABDOMINAL  SURGERY   IN  GENERAL 

which  may  be  easily  accessible  from  either  iliac  region  or  the  hypo- 
chondrium.  But  the  transverse  colon  is  easily  distinguished  from  other 
portions  of  the  large  bowel  because  it  has  the  great  omentum  attached 
to  it.  The  sigmoid  and  cecum  are  readily  distinguished  from  each 
other  by  their  mesenteric  insertions. 

The  mesentery  of  the  small  intestine,  as  already  noted,  crosses  the 
lumbar  spine  obliquely,  beginning  above  on  the  left,  and  ending  at 
the  cecal  region  on  the  right.  The  direction  in  which  a  coil  of  small 
bowel  is  running  (i.  e.,  which  end  is  nearer  the  duodenojejunal  junc- 
ture) can  be  ascertained  by  paying  attention  to  the  attachment  of  its 
mesentery.  The  coil  of  bowel  to  be  investigated  should  be  withdrawn 
from  the  abdomen,  spread  out,  and  untwisted,  until  the  fingers  can 
follow  the  mesentery  down  to  its  origin  or  root  along  the  lumbar 
spine.  If  the  bowel  is  not  rotated  on  its  mesentery,  it  is  evident  that 
it  is  running  in  the  same  direction  as  the  root  of  the  mesentery,  and 
hence  that  its  upper  (duodenal)  end  is  nearer  the  epigastrium  than  is 
its  lower  (cecal)  end.  The  upper  end  of  the  jejunum  is  readily  found 
by  lifting  the  great  omentum  and  with  it  the  transverse  colon  out  of 
the  abdomen,  and  turning  these  structures  upward  on  the  patient's 
thorax.  This  makes  the  transverse  mesocolon  taut,  and  the  jejunum 
is  seen  emerging  from  its  lower  layer  just  to  the  left  of  the  spinal 
column.  This  is  the  duodeno-jejunal  juncture.  The  duodenum  here 
is  retroperitoneal,  and  the  first  intraperitoneal  coil  of  gut  is  the  origin 
of  the  jejunum.  This  is  an  important  landmark  in  gastrojejunostomy. 
The  lower  end  of  the  ileum,  or  the  ileo-cecal  juncture,  is  readily  found 
by  running  the  fingers  upward  along  the  external  iliac  vessels  as  they 
lie  at  the  brim  of  the  true  pelvis.  The  structure  which  arrests 
the  fingers  in  the  neighborhood  of  the  right  sacro-iliac  joint,  will  be  the 
termination  of  the  mesentery  of  the  ileum  where  this  passes  into 
the  cecum.  With  a  little  practice  it  is  not  difficult  to  scoop  up  into  the 
wound,  on  the  finger  tips,  the  ileo-cecal  loop,  and  thus  to  bring  the 
appendix  vermiformis  into  view.  Monks  (1903)  conducted  studies 
in  the  hope  of  being  able  to  differentiate  at  operation  between  dif- 
ferent portions  of  the  jejuno-ileum,  without  the  necessity  of  tracing 
the  entire  small  intestine  downward  from  its  origin  or  upward  from  its 
termination.  Chief  reliance  is  placed  on  the  arrangement  of  the 
mesenteric  bloodvessels.  High  in  the  jejunum  there  are  only  primary 
vascular  loops,  with  perhaps  an  occasional  secondary  loop,  and  the 
vasa  recta  are  from  3  to  5  cm.  long  (Fig.  897).  Midway,  say  at  3 
meters  from  either  end,  the  secondary  loops  are  a  prominent  feature  of 
the  mesenteric  vessels,  and  the  vasa  recta  are  shorter  (Fig.  898).  In 
the  lower  ileum  the  vessels  are  much  less  easily  distinguished,  owing 
to  the  deposition  of  fat  in  the  mesentery;  the  loops,  if  visible,  are 
much  more  complex,  and  the  vasa  recta  are  short  and  irregular  (Fig. 
899).  The  upper  jejunum  is  larger  in  diameter,  its  walls  are  thicker, 
and  often  the  valvulse  conniventes  are  palpable,  or  they  may  be  visible 
by  transmitted  light.  The  lower  ileum  is  smaller,  and  its  walls  are 
thinner. 


INTESTINAL  LOCALIZATION 


879 


Fig.  897. — The  mesenteric  arteries  in  the  upper  portion  of  the  jejunum.    There 
are  only  primary  vascular  loops,  and  the  vasa  recta  are  long. 


Fig. 


-The  mesenteric  arteries  in  the  middle  of  the  jejuno-ileum.     Secondary 
loops  are  well-developed,  and  the  vasa  recta  are  shorter. 


Fig.  899. — In  the  lower  ileum  the  mesenteric  bloodvessels  can  hardly  be  distinguished, 
owing  to  the  deposit  of  fat.  The  preparations  shown  in  Figs.  897,  898,  and  899  are  from 
the  Laboratory  of  Operative  Surgery  in  the  University  of  Pennsylvania. 


SSI) 


ABDOMINAL  SURGERY  IN  GENERAL 


Intestinal  Sutures. — The  underlying  principle  in  suture  of  organs 
covered  with  peritoneum  is  to  bring  serous  surfaces  into  contact. 
This  principle  appears  to  have  been  introduced  by  Jobert  de  Lamballe 
in  1824.  It  is  analogous  to  the  principle  adopted  in  surgery  of  the 
vascular  system  (Chapter  X),  always  to  bring  intima  into  contact 
with  intima.  Such  apposition,  both  of  the  intima  which  lines  blood- 
vessels and  of  the  peritoneum  which  covers  the  abdominal  viscera, 
results  in  much  more  rapid  and  certain  union  than  where  the  muscular 
or  fibrous  layers  of  these  structures  are  sutured  without  bringing  their 
serous  surfaces  into  contact. 

Any  suture  which  brings  serosa  into  contact  with  serosa  may  be 
called  a  sero-serous  suture.  There  are  many  varieties  of  this  suture 
in  use  at  the  present  day,  to  which  the  names  of  various  surgeons 
have  been  attached.  As  already  mentioned,  this  principle  was  used 
by  Jobert  in  1824;  but  in  1826  its  application  was  simplified  by  Lem- 
bert,  and  to  this  day  an  interrupted  sero-serous  suture  is  known  as  a 
Lembert  suture  (Fig.  900).  If  the  suture  did  not  hold  well  he  included 


Fig 


900. — Perforation  of  the  bowel,  being 
closed  by  three  Lembert  sutures. 


Fig.  901. — a,  Czerny-Lembert  suture; 
b,  Albert-Lembert  suture  not  pulled  tight. 
(.See  the  text.) 


tissues  down  to  the  mucous  coat  of  the  bowel,  and  Halsted,  in  1887, 
renewed  this  injunction.  It  is  easy  to  tell  by  the  sensation  imparted 
to  the  surgeon's  hand,  when  the  needle  has  caught  up  the  tough 
submucous  tissue.  As  a  matter  of  fact  the  needle  often,  if  not  indeed 
usually,  penetrates  all  the  coats  of  the  intestine;  and  this  makes 
no  difference  so  long  as  no  fecal  leakage  occurs  along  the  needle 
track.  This  is  prevented  by  the  use  of  (1)  round-pointed  needles, 
and  (2)  linen  celluloid  thread  (Pagenstecher's  suture,  1900),  which 
possesses  no  capillarity.  This  suture  material  becomes  encapsulated 
and  may  remain  permanently. 

For  additional  security  in  intestinal  wounds,  and  especially  to  check 
bleeding  from  the  cut  margins  of  the  bowel,  it  is  the  rule  to  employ 
also  a  through-and-through  suture,  which  passes  through  all  the  coats 
of  the  intestine.  This  is  inserted  before  the  sero-serous  suture,  is 
knotted  within  the  lumen  of  the  bowel,  and  should  be  of  absorbable 
material  so  that  it  will  ulcerate  out  into  the  intestinal  canal  when 
union  is  firm.    Chromic  catgut  (No.  0  or  No.  1)  is  the  best  material. 


INTESTINAL  SUTURES 


881 


The  principle  of  the  through-and-through  suture  knotted  within  the 
lumen  of  the  bowel  we  owe  to  Albert.  A  diagram  of  the  Albert- 
Lembert  suture  is  shown  in  Fig.  901,  b.  Czerny's  suture  did  not 
penetrate  the  mucosa,  and  was  not  knotted  within  the  bowel  (Fig. 
901,  a). 

Suture  of  Punctures  and  Perforations. — A  mere  puncture  may  be 
inverted  by  a  couple  of  Lembert  sutures  (Fig.  900)  or  by  the  first 
points  of  a  Gely  suture  (1844)  (Fig.  902).  A  perforation  usually  may 
be  closed  by  a  purse-string  suture  (Fig.  903,  6),  but  if  it  is  large  it 
must  be  sutured  as  a  wound  in  a  direction  either  transverse  or  parallel 
to  the  long  axis  of  the  intestine,  whichever  puckers  the  bowel  less. 
As  there  seldom  is  bleeding  from  the  edges  of  a  perforation  it  is  not 
usually  necessary  to  use  a  through-and-through  suture,  the  sero-serous 
suture  being  sufficient. 


Fig.  902.— Gely 's  suture. 


Fig.  903. — a,  The  first  points  of  a  Gely 
suture,  used  to  close  a  puncture,  b,  a 
purse-string  suture,  used  to  close  a  per- 
foration. 


Suture  of  Incisions  or  Wounds. — Gunshot  wounds  resemble  perfora- 
tions and  require  the  same  treatment.  Ruptures,  lacerated  and 
incised  wounds,  especially  operation  wounds,  usually  require  first 
a  through-and-through  suture  to  check  hemorrhage.  This  may  be 
either  interrupted  or  continuous.  The  needle  is  entered  at  one  end 
of  the  incision,  from  the  mucous  surface,  emerges  on  the  peritoneal 
surface,  crosses  to  the  opposite  side  of  the  incision,  and  there  again 
penetrates  all  the  coats  of  the  bowel  from  the  serous  to  the  mucous 
surface.  It  is  then  knotted;  the  knot  thus  lies  within  the  lumen  of  the 
bowel.  If  an  interrupted  suture  is  desired,  both  ends  of  the  thread 
are  cut  short,  and  other  sutures  introduced  about  one-half  a  centi- 
meter apart  until  the  wound  is  closed.  If  a  continuous  suture  is  pre- 
ferred, only  the  free  end  of  the  thread  is  cut  short,  and  the  needle  is 
re-introduced  on  one  side  of  the  wound  from  its  mucous  surface,  and 
traversing  all  the  coats  of  the  bowel,  emerges  on  the  peritoneal  sur- 
face. The  needle  is  then  carried  across  the  wound  to  its  opposite  lip; 
here  enters  the  serous  surface  of  the  bowel,  traverses  all  its  coats,  and 
emerges  on  the  mucous  surface.  This  completes  the  second  stitch, 
and  the  thread  is  then  drawn  taut,  carefully  inverting  the  lips  of  the 
56 


SS2 


AIWOMINAL  SURGERY  IN  GENERAL 


wound  ;is  this  is  done.  Each  similar  stitch  is  pulled  taut  until  the 
other  end  of  the  wound  is  reached,  when  the  suture  is  knotted  and  the 
knot  is  allowed  to  retract  within  the  lumen  of  the  bowel  (Fig.  904). 


Fig.  !>04. — Closure  of  an  intestinal 
wound  by  a  continuous  through-and- 
through  suture.  The  knots  lie  within 
the  lumen  of  the  gut.       . 


Fig.  905.- — Continuous  sero-serous  suture 
(Dupuytren's  suture). 


To  reinforce  this  through-and-through  suture,  a  continuous  sero-serous 
suture  (known  also  as  Dupuytren's  suture)  is  applied  (Fig.  905).  Any 
point  which  seems  weak  may  be  reinforced  again  by  an  interrupted 


Fig.  906. — Right-angled  sero-serous  suture  of  Cushing. 

suture.  When  there  is  much  tension  on  the  parts  a  sero-serous  suture, 
inserted  as  shown  in  Fig.  906,  usually  holds  better;  it  is  known  as  the 
right-angled  sero-serous  suture   (also  by  the  name  of  Hayward  W. 


Fig.  907. — Interrupted  mattress  suture. 
(Deaver  and  Ashhurst.) 


Fig.  908. — Continuous  mattress  suture. 
(Deaver  and  Ashhurst.) 


Cushing,  1889).  Or  a  mattress  suture,  either  interrupted  (Fig.  907) 
or  continuous  (Fig.  908)  may  be  employed;  this  is  known  by  HalstecTs 
name  (1887). 

Intestinal  Resection. — When  it  is  necessary  to  resect  a  portion  of  the 
intestinal  canal,  the  mesentery  is  first  tied  off.     This  is  done  by  a 


INTESTINAL  RESECTION 


883 


series  of  interlocking  ligatures  applied  2  or  3  cm.  from  the  intes- 
tinal attachment  of  the  mesentery,  and  never  over  quite  as  wide  an 
area  as  the  length  of  gut  to  be  removed,  for  fear  of  endangering  its 
vitality.  The  gut  above  and  below  the  diseased  area  is  then  double 
clamped :  suitable  clamps,  with  their  blades  covered  by  rubber  tubing, 
introduced  into  surgery  by  Rydygier  (1881),  and  popularized  by 
Doyen  (1900),  may  be  applied  to  healthy  bowel,  and,  if  clamped  only 
tight  enough  to  appose  the  mucous  surfaces,  may  remain  in  place 
a  most  an  hour  without  inflicting  any  injury.  These  clamps  should 
have  light,  elastic  blades,  which  meet  at  their  tips  before  the  bodies 
of  the  blades  come  together  (Fig.  909).  They  prevent  fecal  extrava- 
sation and  also  serve  the  purpose  of  temporary  hemostasis,  like  the 
elastic  band  of  Ej march  used  in  amputating.  In  emergency  pieces  of 
tape  jnay£be[tied^around  the  bowel. 


Fig.  909. — Clamps  used  in  gastric  and  intestinal  surgery.    Note  the  form  of  the  blades; 
[in  the  upper  (three-bladed)  forceps  the  rubber  tubing  is  in  place. 


Such  clamps  should  be  applied  to  the  healthy  bowel  an  inch  or  more 
above  and  below  the  proposed  limits  of  resection.  Any  ordinary  clamp 
forceps  are  then  applied  at  the  limits  of  the  diseased  area,  which  is  thus 
cut  at  each  end  between  two  pairs  of  clamps  (Fig.  910),  so  that  no 
fecal  extravasation  occurs. 

The  subsequent  procedure  depends  upon  whether  it  is  desired  to 
restore  the  continuity  of  the  intestinal  canal  by  anastomosis,  or  to 
establish  a  false  anus  in  the  wound.  The  best  way  to  establish  a 
false  anus  after  intestinal  resection  is  to  suture  the.  two  coils  of  bowel 
together  like  a  double-barrelled  shotgun — "  en  canon  de  fusil"  as  the 
French  call  it.  This  is  easily  accomplished  by  a  few  sero-serous 
sutures.  Then  the  circumference  of  each  intestinal  coil  is  sutured 
to  the  parietal  peritoneum,  leaving  about  an  inch  of  each  gut  pro- 
truding from  the  wound.    The  clamps  used  for  resection  may  be  left 


SSI 


ABDOMINAL  SURGERY   IN  GENERAL 


on  the  protruding  ends  for  a  few  days  (or  until  the  peritoneal  cavity 
is  shut  off  by  adhesions),  if  there  is  no  urgent  need  to  secure  a  fecal 
evacuation;  or  the  ends  may  be  simply  ligated  and  be  left  to  open 
themselves  when  the  slough  separates.  Other  methods  of  forming  a 
false  anus  are  discussed  at  p.  9G9;  and  the  treatment  of  this  condition 
is  considered  at  p.  946. 


Fig.  910. — Intestinal  resection.    After  the  mesentery  has  been  ligated  and  cut  close  to 
the  bowel,  the  resection  clamps  are  applied,  and  the  diseased  bowel  is  cut  away. 

Intestinal  Anastomosis. — This  may  be  accomplished  by  uniting  the 
gut  end-to-end  (circular  enterorrhaphy) ;  or,  after  closing  the  open  ends 
of  the  intestines,  these  may  be  placed  side  by  side  and  a  lateral  anas- 
tomosis may  be  established  (N.  Senn,  1889).  By  an  implantation  is 
understood  an  operation  in  which  the  end  of  one  bowel  is  sutured  into 
the  side  of  another,  much  as  the  ileum  is  implanted  into  the  cecum. 

End-to  end  Anastomosis. — The  rubber-covered  clamps  employed 
during  the  intestinal  resection  are  left  in  place.  By  bringing  them 
parallel  to  each  other,  the  ends  of  the  gut  are  approximated;  these 
then  look  at  the  surgeon  like  a  double-barrelled  shot-gun.  This  brings 
four  layers  of  intestinal  wall  to  view,  two  of  which  are  apposed. 

1.  First,  a  continuous  through-and-through  suture  of  chromic 
catgut  is  applied:  this  is  begun  by  introducing  the  needle  from  the 
mucous  surface  of  that  coil  of  gut  on  the  operator's  right,  at  the  anti- 
mesenteric  point.  The  needle  is  pushed  through  the  apposed  intes- 
tinal walls  from  the  lumen  of  one  gut  into  that  of  the  other,  where  it 
emerges  on  the  mucous  surface,  having  in  its  course  traversed  all 
intervening  layers  of  both  guts :  of  the  first  coil  from  the  mucous  to  the 
serous,  and  of  the  second  coil  from  the  serous  to  the  mucous  surface. 
The  first  stitch  is  then  tied,  the  knot  coming  within  the  lumen  of  the 
bowel.  The  end  is  left  long.  The  suturing  is  then  continued  (Fig. 
911)  toward  the  mesenteric  attachment,  and  when  this  is  reached  the 
suture  is  passed  as  indicated  in  Fig.  912.  The  suture  is  continued  around 
the  margin  of  the  gut,  always  passing  from  the  mucous  to  the  serous 
surface  of  the  first  coil  and  from  the  serous  to  the  mucous  surface  of 


INTESTINAL  ANASTOMOSIS 


885 


the  second  coil  of  bowel.  When  the  point  of  beginning  is  reached  at 
last,  the  suture  is  terminated  by  knotting  it  to  the  original  end,  which 
was  left  long  for  this  purpose.  When  both  ends  are  cut  short,  the  knot 
disappears  into  the  lumen  of  the  bowel. 

2.  The  clamps  may  then  be  removed,  and  the  operation  is  com- 
pleted by  passing  a  continuous  sero-serous  suture  around  the  entire 
anastomosis,  thus  reinforcing  the  through-and-through  suture. 

3.  The  mesentery  will  become  redundant  when  the  intestinal  ends 
are  approximated;  its  free  border  may  be  stitched  to  the  anastomosis. 


Fig.    911. — End-to-end    anastomosis.     The 
through-and-through  suture  has  been  started. 


Fig.  912. — End-to-end  anastomosis. 
Passing  the  through  and  through 
suture  at  the  mesenteric  attachment. 


Fig.  913. — Maunsell's  method  of  circular  enterorrhaphy.  a,  the  incision  in  one  coil 
of  intestine;  b,  the  open  ends  of  both  coils  evaginated  through  this  incision,  to  facilitate 
suturing;  c,  the  operation  completed. 

Maunsell  (1892)  thought  it  facilitated  the  operation  of  circular 
enterorrhaphy  to  evaginate  the  divided  ends  through  a  longitudinal 
incision  in  one  of  the  coils  of  intestine.  After  suture  of  the  divided  ends 
has  been  thus  completed,  from  their  mucous  surface,  they  are  replaced, 


886 


ABDOMINAL  SURGERY  IN  GENERAL 


and  the  intestinal  incision  through  which  they  were  withdrawn  is 
closed.  A  partial  intussusception  of  the  sutured  ends  remains  (Fig. 
913). 

M.  E.  Connell  (1892)  advocated  only  interrupted-  mattress  sutures, 
penetrating  all  the  coats  of  the  bowel,  and  tied  on  their  mucous 
surface. 

Lateral  Anastomosis. — The  open  ends  of  the  resected  bowel  must 
first  be  closed.  If  the  lumen  of  the  gut  is  small,  it  is  sufficient  to  apply 
a  ligature  in  the  groove  made  by  a  crushing  clamp,  as  in  the  operation 
of  appendicectomy  (p.  907)  and  to  invert  this  ligature  by  a  purse- 
string  sero-serous  suture.  When  the  guts  are  to  be  left  in  or  near 
the  wound  after  the  lateral  anastomosis  has  been  completed  (as  in 
some  cases  of  resection  for  strangulated  hernia),  it  is  sufficient  to  apply 
a  strong  ligature,  as  above  described,  without  a  secondary  inverting 
purse-string  suture.  Thus  time  is  saved.  In  most  instances,  however, 
and  especially  where  the  lumen  of  the  resected  gut  is  of  large  size, 
it  is  safer  to  close  the  end  of  the  bowel  by  two  layers  of  sutures,  the 
first  being  a  continuous  through -and-through  suture  of  chromic  catgut, 
and  the  second  a  linen  sero-serous  suture. 


Fig.  914. — Lateral   anastomosis  with 
intestinal  coils  in  iso-peristaltic  relation. 


) 


Fig.  915. — Lateral  anastomosis 
with  intestinal  coils  in  anti-peri- 
staltic relation. 


Lateral  anastomosis  should  be  made  in  an  iso-peristaltic  direction 
(Fig.  914);  though  where  afferent  and  efferent  loops  are  sutured 
together  en  canon  de  fusil,  and  an  anastomosis  is  subsequently  estab- 
lished, the  antiperistaltic  direction  of  the  anastomosis  appears  to  make 
little  difference  (Fig.  915). 

The  formation  of  a  lateral  anastomosis  is  much  facilitated  by  the 
use  of  rubber-covered  intestinal  clamps.  The  three-bladed  clamp  is 
very  convenient  (Fig.  909).  The  clamp  shou'd  be  applied  so  as  to 
embrace  a  considerably  greater  area  of  bowel  than  that  concerned  in 
the  anastomosis.  The  anastomosis  is  made  on  the  free  (antimesenteric) 
border  of  the  intestinal  loops. 

1.  The  first  step  consists  in  the  insertion  of  a  continuous  linen  sero- 
serous  suture  close  to  the  median  blade  of  the  clamp,  for  a  distance 
a  little  longer  than  the  size  of  the  proposed  intestinal  opening,  say 
about  8  to  10  cm.  This  suture  is  begun  at  one  end  of  the  proposed 
intestinal  opening,  where  it  is  knotted,  the  free  end  being  left  long; 
it  is  continued  in  a  straight  line  to  the  other  end  of  the  proposed  anas- 
tomosis, uniting  the  two  coils  of  intestine,  as  indicated  in  Fig.  91G. 


LATERAL  ANASTOMOSIS 


887 


When  this  point  is  reached  the  suture  is  not  cut,  but  the  needle,  still 
threaded,  is  laid  aside  temporarily,  to  be  used  again  before  the  close 
of  the  operation.  This  needle  and  thread  will  be  referred  to  as  the 
sero-serous  suture. 


Fig.  916. — Lateral  anastomosis:  the  clamp  has  been  placed;  the  sero-serous  suture 
has  been  inserted,  close  to  the  middle  blade  of  the  forceps;  and  the  coils  of  intestine 
have  been  opened.  At  the  near  angle  of  the  intestinal  incisions  the  needle  is  entered  for 
the  commencement  of  the  through-and-through  suture. 

2.  The  surgeon  then  makes  a  longitudinal  incision  in  one  of  the 
coils  of  bowel,  about  one  centimeter  distant  from  and  parallel  to  the 
sero-serous  suture  already  applied,  and  about  6  to  8  cm.  in  length. 
This  incision  divides  first  the  serous  and  muscular  coats  of  the  gut; 
as  these  retract  the  mucosa  pouts  into  the  incision.  The  mucosa  is 
cautiously  opened  at  one  point,  so  as  not  to  wound  the  opposite  wall 
of  the  bowel.     Any  discharge  from  the  lumen  of  the  bowel  is  wiped 


sss  ABDOMINAL  SURGERY  IN  GENERAL 

carefully  away.  Then  the  opening  in  the  mucosa  is  enlarged  by 
scissors  to  the  full  extent  of  the  intestinal  incision.  If  the  mucosa 
seems  redundant,  as  is  often  the  case  in  the  small  intestine,  it  should 
be  excised.  The  other  coil  of  gut  is  then  opened  in  a  similar  way  for 
an  equal  distance.  There  are  now  exposed  in  the  wound  two  apposed 
loops  of  intestine,  each  with  a  longitudinal  incision  in  its  antimes- 
enteric  border.  Each  of  these  incisions  has  two  lips,  an  anterior  and 
a  posterior.  The  two  posterior  lips  are  fairly  close  together,  while 
the  anterior  lips  are  some  distance  apart.  For  purposes  of  descrip- 
tion it  is  convenient  to  apply  definite  names  to  these  structures:  we 
may  speak  of  the  coil  of  bowrel  on  the  operator's  right  as  the  first  gut, 
and  that  on  h:s  left  as  the  second  gut  (frequently  it  is  impossible  to 
know  which  of  these  is  the  afferent  and  wThich  is  the  efferent  loop); 
each  of  these  guts  has  an  incision  with  an  anterior  and  a  -posterior  lip; 
the  posterior  lips  are  closely  apposed  to  each  other.  Where  the 
anterior  and  posterior  lip  of  each  incision  join,  is  found  the  angle  of 
the  incision;  one  angle  is  at  the  end  of  the  intestinal  incision  away 
from  the  operator  (the  far  angle  of  the  incision)  and  the  other  is  at  the 
near  end  of  the  incision  (the  near  angle  of  the  incision). 

3.  A  through-and-through  continuous  suture  of  chromic  catgut  is 
now  to  be  inserted.  The  needle  is  entered  at  the  near  angle  of  the 
incision  in  the  first  gut,  from  its  mucous  surface,  and  traverses  all  its 
coats,  emerging  on  its  serous  surface;  it  is  then  inserted  at  the  near 
angle  of  the  second  gut,  passing  from  its  serous  to  its  mucous  surface. 
This  stitch  is  then  tied,  the  knot  coming  within  the  lumen  of  the  bowel. 
The  end  of  the  suture  is  left  long;  it  should  not  be  confused  writh  the 
end  of  the  sero-serous  suture  (linen),  which  also  wras  left  long.  The 
through-and-through  chromic  catgut  suture  is  continued  away  from 
the  operator,  uniting  the  posterior  lips  of  the  intestinal  incisions, 
as  shown  in  Fig.  917,  until  the  far  angles  of  the  incisions  are  reached. 
During  this  time  the  needle  is  passed  always  from  the  mucous  surface 
of  the  first  gut  through  all  its  coats  to  its  serous  surface,  and  imme- 
diately into  the  serous  surface  of  the  second  gut,  emerging  on  the 
mucous  surface  of  the  second  gut.  Then  the  thread  is  drawn  taut; 
the  needle  is  carried  back  to  the  side  from  which  it  started,  and  again 
enters  the  mucous  surface  of  the  first  gut,  traverses  all  its  coats  to 
emerge  on  its  serous  surface,  and  at  once  enters  the  serous  surface  of 
the  second  gut,  and,  traversing  all  its  coats,  emerges  on  its  mucous 
surface  in  the  lumen  of  the  second  gut.  This  is  accomplished  each 
time  by  one  push  of  the  needle,  which  is  enabled  to  pass  through  the 
walls  of  both  guts  "all  at  one  bite,"  because  the  posterior  lips  of  the 
intestinal  incisions  are  so  closely  approximated.  When,  however,  the 
far  angles  of  the  intestinal  openings  are  reached,  it  is  no  longer  possible 
for  the  needle  to  pass  through  the  w^alls  of  both  guts  all  at  one  bite, 
but  it  is  necessary  for  it  to  be  passed  through  each  separately.  But 
the  same  method  of  suturing  may  be  continued:  thus  the  needle 
always  enters  the  first  gut  from  its  mucous  surface  and  emerges  on  its 
serous  surface;  it  then  is  carried  across  to  the  free  margin  of  the 


LATERAL  ANASTOMOSIS 


889 


second  gut  (at  its  far  angle  or  on  its  anterior  lip),  and  always  enters 
its  wall  from  the  serous  surface  and  emerges  on  its  mucous  surface. 
This  is  readily  understood  by  reference  to  Fig.  917.  This  method  of 
suturing  is  continued  along  the  anterior  lips  of  the  intestinal  incisions 
toward  the  operator  until  the  near  angles  of  the  incisions  are  reached, 
when  a  complete  circumference  will  have  been  traversed  by  the 
through-and-through  chromic  catgut  suture,  which  is  finally  knotted 
to  its  original  end,  which  was  left  long  for  this  purpose  at  the  starting- 
point,  the  near  angles  of  the  intestinal  incisions.  As  this  suture  is 
being  inserted  in  the  anterior  lips  these  should  be  carefully  inverted 


Fig.  917.  —  Lateral  anastomosis:  the 
through-and-through  suture  has  united 
the  posterior  lips  of  the  intestinal  inci- 
sions, and  the  far  end  of  these  incisions 
has  been  reached. 


Fig.  918.  —  Lateral  anastomosis:  the  far 
angles  of  the  intestinal  incisions  have  been 
sutured,  and  the  anterior  lips  of  the  incisions 
are  now  being  united  by  the  through-and- 
through  suture  which  is  passed  in  a  manner 
similar  to  the  sero-serous  suture  shown  in 
Fig.  906. 


so  as  to  ensure  accurate  contact  of  their  serous  surfaces.  If  there 
is  difficulty  in  securing  proper  inversion  of  the  anterior  lips,  it  is  a 
very  good  plan  to  use  for  this  part  of  the  operation  a  continuous 
right-angled  suture  similar  to  the  sero-serous  suture  of  Cushing  (Fig. 
906),  except  that  here  the  right-angled  suture  should  penetrate  all 
the  coats  of  the  intestine,  leaving  the  loop  of  the  suture  always  on 
the  mucous  surface  of  the  bowel  (Fig.  918).  This  is  known  as  C.  H. 
Mayo's  suture  (1905).  It  is  nothing  else  than  a  right-angled  through- 
and-through  suture. 

4.  When  the  application  of  the  through-and-through  suture  has  been 
completed,  the  rubber  clamps  may  be  released,  but  should  not  be 


890  ABDOMINAL  SURGERY  IN  GENERAL 

removed  from  their  position,  as  they  serve  to  keep  the  parts  accessible 
for  the  application  of  the  final  suture.  This  is  a  continuation  of  the 
sero-serous  suture  first  applied,  the  needle  of  which,  still  threaded, 
was  laid  aside  temporarily  before  the  application  of  the  through-and- 
through  suture  was  commenced.  This  sero-serous  suture  is  now  con- 
tinued over  the  inverted  anterior  lips  of  the  intestinal  anastomosis, 
further  inverting  them  and  burying  from  sight  the  through-and-through 
suture.  The  sero-serous  suture  is  finally  arrested  at  the  near  angle  of 
the  anastomosis,  where  it  is  knotted  to  its  own  original  free  end,  which 
was  left  long  for  this  purpose.  The  clamps  are  then  entirely  removed ; 
the  anastomosis  is  inspected  on  all  sides,  any  weak  spot  being  reinforced 
by  one  or  two  additional  interrupted  sero-serous  sutures.  The  intestines 
are  then  replaced  within  the  abdomen. 

The  advantages  of  lateral  over  end-to-end  anastomosis  are  the  follow- 
ing: the  opening  may  be  made  of  any  desired  size;  there  is  no  mesen- 
teric attachment  to  be  included  in  the  sutures,  and  no  fear  of  leakage 
at  this  weak  point.  The  chief  disadvantage  is  the  additional  time 
required  for  its  performance,  when  it  is  employed  after  intestinal  re- 
section, because  then  it  involves  also  closure  of  two  ends  of  bowel. 
After  lateral  anastomosis  following  intestinal  resection  the  coils  of 
bowel  involved  tend  to  straighten  out,  so  that  after  some  years  little 
or  no  trace  of  the  anastomosis  can  be  found,  even  when  it  was  made 
in  an  antiperistaltic  direction.  Lateral  anastomosis  I  believe  should 
be  preferred  (1)  whenever  the  large  bowel  (except  perhaps  the  trans- 
verse colon  or  sigmoid)  is  concerned,  as  this  has  a  relatively  large  extra- 
peritoneal surface  and,  therefore,  usually  is  not  well  adapted  for  an 
end-to-end  anastomosis ;  (2)  in  cases  where  the  two  coils  of  gut  to  be 
anastomosed  differ  much  in  diameter,  though  by  careful  suture  or  by 
cutting  the  smaller  intestinal  loop  obliquely  it  is  possible  to  employ 
end-to-end  anastomosis  even  under  such  circumstances;  and  (3)  in  cases 
where  the  intestinal  walls  are  altered  from  inflammatory  changes,  as 
in  most  cases  of  acute  intestinal  obstruction,  strangulated  hernia,  etc. 
End-to-end  anastomosis  I  think  is  best  limited  to  resections  of  small 
intestine  not  undertaken  in  the  presence  of  acute  disease. 

Mechanical  devices  for  intestinal  anastomosis  are  not  much  used  by 
surgeons  any  more.  The  Murphy  button,  introduced  by  J.  B.  Murphy, 
in  1892,  is  still  the  most  popular  in  this  country,  as  is  the  somewhat 
similar  contrivance  of  Jaboulay,  in  France,  and  Mayo  Robson's  bone 
bobbin,  in  England.  The  Murphy  button  is  a  very  ingenious  contriv- 
ance, made  of  metal,  nickel-plated;  it  consists  of  two  parts  (Fig.  919), 
one  of  which  is  inserted  through  a  small  incision  into  each  of  the  loops 
of  bowel  to  be  anastomosed,  and  is  held  in  place  by  a  purse-string 
suture  which  puckers  the  bowel  around  the  half  of  the  button  inserted. 
The  projecting  shanks  of  each  end  of  the  button  are  then  forced 
together,  the  male  within  the  female;  the  two  halves  of  the  button  are 
thus  held  together  automatically  by  a  spring.  Serous  surfaces  are  thus 
brought  into  broad  apposition  (Fig.  920).  The  union  may  be  reinforced 
by  a  few  interrupted  sero-serous  sutures.    The  button  is  provided  with 


INJURIES  OF  THE  ABDOMEN 


891 


a  lumen  in  its  center,  and  if  all  goes  well,  it  ulcerates  into  the  lumen 
of  the  intestine  in  ten  days  or  two  weeks  and  is  passed  by  rectum. 
During  the  application  of  the  button  its  lumen  may  be  filled  with 
cocoa  butter,  which  will  prevent  fecal  extravasation  temporarily,  but 
melts  as  soon  as  the  intestines  are  returned  to  the  abdomen.  I  have 
never  used  any  mechanical  device  in  effecting  intestinal  anastomosis, 
but  believe  the  Murphy  button  better  than  any  other  such  appliance. 
It  is  particularly  indicated  where  the  parts  concerned  in  the  operation 
cannot  be  brought  into  the  wound  so  as  to  render  accurate  suture 
possible,  or  where  very  rapid  conclusion  of  the  operation  becomes 
imperative.  The  chief  danger  from  the  use  of  the  button  is  that  its 
mechanism  may  be  defective,  so  that  it  may  ulcerate  out  too  soon, 
allowing  fecal  extravasation  and  causing  death  from  peritonitis.  It 
should  be  an  invariable  rule  for  the  surgeon  himself  personally  to  test 


_  Fig.  919. — The  Murphy  button  for  intes- 
tinal anastomosis;  above,  the  female  half; 
below,  the  male  half  of  the  button. 


Fig.  920. — Two  coils  of  intestine 
anastomosed  by  means  of  the  Murphy 
button. 


the  mechanism  of  the  button  thoroughly  and  several  times  before 
the  operation  is  commenced.  Occasionally  the  button  has  caused 
intestinal  obstruction. 


INJURIES  OF  THE  ABDOMEN. 

Subcutaneous  Injuries. — These  may  affect  the  abdominal  wall 
only,  or  there  may  be  visceral  injury  with  or  without  injury  of  the 
overlying  structures.  In  almost  all  cases  the  injury  is  by  direct  vio- 
lence, blunt  force  in  the  form  of  a  blow,  a  kick,  a  fall,  or  a  crush,  being 
applied  to  the  abdominal  wall.  If  the  abdominal  muscles  are  rigidly 
contracted,  the  blow  a  glancing  one,  the  force  not  very  great,  and  the 
viscera  not  distended  or  weakened  by  disease,  only  a  contusion  of  the 
abdominal  wall  may  result.  If  the  force  is  greater,  rupture  of  the 
abdominal  wall  may  occur;  this  was  referred  to  at  p.  305.    Rupture 


892  ABDOMINAL  SURGERY  IN  GENERAL 

of  one  of  the  abdominal  muscles  from  voluntary  contraction  sometimes 
occurs  in  cases  of  typhoid  fever;  I  have  seen  one  case,  apparently  of 
this  nature,  complicating  pneumonia.  In  such  cases  there  is  metas- 
tatic infection. 

Traumatic  Iliac  Abscess  deserves  recognition  as  a  clinical  entity: 
an  extraperitoneal  abscess,  right  or  left,  forms  as  the  result  of  trauma 
or  sprain.  Probably  the  injury  causes  a  hematoma,  which  becomes 
infected  through  the  blood  stream.  In  some  cases  the  abscess  origin- 
ates in  lymphadenitis  of  the  nodes  along  the  external  iliac  artery; 
there  is  no  evidence  that  it  results  from  vertebral  osteomyelitis.  The 
diagnosis  must  be  made  from  appendicular  abscess  (p.  910),  and  from 
2?50O5  abscess  (p.  652).  Treatment  consists  in  opening  and  draining 
the  abscess  by  an  incision  close  to  Poupart's  ligament. 

When  there  is  visceral  injury  it  usually  is  because  the  abdominal 
muscles  have  been  taken  off  their  guard,  or  because  they  are  very 
flabby  and  weak.  Then  the  force  need  not  be  very  great,  especially 
if  the  hollow  viscera  are  distended  or  the  solid  viscera  enlarged  by 
disease.  In  these  cases  no  macroscopic  evidence  of  injury  to  the 
abdominal  wall  may  be  found.  Visceral  injury  without  injury  of  the 
abdominal  wall  is  much  more  frequent  than  rupture  of  the  abdominal 
wall  without  visceral  injury.  The  gravity  of  the  injury,  as  pointed 
out  at  p.  195,  depends  largely  upon  the  momentum  of  the  vulnerating 
body :  a  mere  tap  on  the  abdomen  from  a  heavy  swinging  crane,  or 
block  and  tackle,  will  do  much  more  damage  than  a  smart  blow  with 
a  stick.  Sometimes  a  fall  inflicts  injury  by  indirect  violence,  one  of 
the  abdominal  viscera  being  torn  from  its  moorings  by  the  jar  when 
the  patient  lands  on  his  buttocks  or  feet;  but  this  is  very  rare. 

Most  cases  of  abdominal  injury  occur  in  men  during  active  adult 
life,  or  in  children.  An  irreducible  hernia  is  an  important  predisposing 
factor:  not  so  much  that  the  structures  in  the  hernial  sac  are  injured, 
but  because  the  intra-abdominal  organs  are  held  taut,  and  thus  are 
unable  to  escape  from  a  crushing  force.  This  was  the  case  in  two  out 
of  six  adults  upon  whom  I  have  operated  for  subcutaneous  rupture 
of  the  abdominal  viscera. 

The  intestinal  tract  is  most  often  injured.  Its  more  fixed  portions 
(duodeno- jejunal  juncture,  lower  ileum  and  cecum)  are  most  exposed 
to  injury.  The  injury  may  be  a  mere  contusion,  which  may  or  may 
not  terminate  in  gangrene  and  perforation;  rupture  may  occur;  or  the 
bowel  may  be  torn  loose  from  its  mesentery.  Ruptures  usually  occur 
on  the  antimesenteric  border  of  the  gut,  and  seem  to  be  caused  by 
over-distention  of  the  intestine  with  a  resulting  explosive  injury,  a 
coil  of  gut  being  compressed  so  as  to  dam  up  its  contents  against  an 
obstruction,  such  as  the  ileo-cecal  valve  or  a  kink  between  adjacent 
intestinal  loops.  A  few  cases  of  rupture  of  the  large  bowel  have  been 
reported  from  the  injection  of  compressed  air  into  the  rectum.  Rup- 
tures of  the  stomach  have  occurred  from  too  forcible  lavage,  and  from 
artificial  distention  with  Seidlitz  powders;  this  is  especially  to  be  feared 
in  cases  of  gastric  carcinoma,  and  in  unconscious  patients.     Sponta- 


INJURIES  OF  THE  ABDOMEN  893 

neous  rupture  of  the  stomach  has  been  reported  as  a  result  of  vom- 
iting, fermentative  distention,  etc.  Complete  transverse  ruptures 
occur  oftenest  at  the  duodeno-jejunal  juncture.  Crushes  of  the  intes- 
tine result  from  pressure  between  the  body  which  inflicts  the  injury 
and  the  sacral  promontory  or  lumbar  spine.  In  this  way  the  lower 
ileum  is  often  torn  loose  from  its  mesentery. 

The  solid  organs  are  less  often  the  seat  of  injury  than  is  the  gastro- 
intestinal tract.  The  spleen  and  liver  are  much  more  frequently 
injured  than  is  the  pancreas,  which  is  in  a  protected  situation.  The 
liver  or  spleen  may  be  penetrated  by  the  fragments  of  broken  ribs, 
but  usually  the  lesion  is  a  rupture  from  diffuse  compression.  The 
rupture  may  be  entirely  subcapsular,  or  may  extend  to  the  surface 
of  the  organ. 

Symptoms  and  Diagnosis. — Often  there  is  considerable  shock; 
usually  there  is  vomiting;  local  pain  causes  shallow  and  thoracic 
respiration.  Pain  is  the  most  constant  symptom,  and  where  fecal 
extravasation  occurs  it  may  be  agonizing.  The  abdominal  wall  is 
very  rigid,  and  physical  examination  is  unsatisfactory. 

If  there  is  only  a  severe  contusion  of  the  abdominal  wall,  without  vis- 
ceral injury,  the  general  condition  of  the  patient  is  not  much  affected, 
even  at  first,  and  it  rapidly  improves.  The  pain  is  not  very  great, 
but  tenderness  and  rigidity  usually  are  very  pronounced.  It  is  very 
difficult  to  exclude  visceral  injury  certainly,  and  in  most  cases  explora- 
tory laparotomy  is  indicated.  If  there  is  a  large  rupture  of  the  gastro- 
intestinal tract,  permitting  fecal  extravasation,  the  pain  is  extremely 
severe;  but  if  the  rupture  is  very  small  it  may  be  occluded  by  the 
mucosa,1  and  there  may  be  comparatively  little  pain.  Serious  symp- 
toms follow  intra-abdominal  hemorrhage  even  when  there  is  no  injury 
of  the  gastro-intestinal  tube.  A  significant  symptom  in  cases  with 
visceral  injury  is  a  steady  increase  in  the  pulse  rate;  usually  the 
temperature  also  rises,  and  leukocytosis  develops.  Later  the  signs 
of  peritonitis  develop.  If  there  is  a  rupture  of  one  of  the  solid  organs, 
or  of  the  omentum  or  mesentery,  signs  of  internal  hemorrhage  usually 
precede  the  onset  of  peritonitis.  Emphysema  of  the  abdominal  wall 
(a  valuable  but  very  rare  sign),  indicates  rupture  of  a  hollow  viscus. 
The  only  certain  way  to  exclude  visceral  injury  is  by  exploratory 
laparotomy,  and  usually  this  is  postponed  too  long. 

Ruptures  of  the  gastro-intestinal  tract  almost  always  are  due  to  injury 
from  the  front.  Apart  from  the  very  severe  pain,  mentioned  above, 
the  occurrence  of  repeated  vomiting,  of  widespread  tenderness  and 
rigidity,  or  of  blood  in  the  stools,  indicates  injury  of  a  hollow  viscus. 

Rupture  of  the  liver  is  due  to  injury  to  the  right  hypochondriac 
region  or  lower  thorax.  As  noted  above,  fracture  of  the  ribs  may  be 
present,  with  puncture  of  the  liver  by  a  fragment.  The  rupture  usually 
is  in  the  right  lobe,  involves  the  capsule  of  Glisson,  and  permits  intra- 
peritoneal hemorrhage.     The  chief  symptoms  are  those  of  internal 

1  In  all  injuries  sustained  during  life  the  mucosa  is  everted  into  the  rupture; 
this  is  not  the  case  if  the  rupture  takes  place  after  death  (Whitney). 


S<)1  ABDOMINAL  SURGERY  IN  GENERAL 

hemorrhage.  Jaundice  may  develop  after  several  days.  Rupture  of 
the  gall-bladder  or  bile-ducts  allows  extravasation  of  bile,  and  peri- 
tonitis develops  early  or  late  according  to  the  infectiousness  of  the 
bile. 

Rupture  of  the  spleen  is  most  frequent  in  cases  of  malarial  hyper- 
trophy, and  under  such  circumstances  may  occur  from  very  slight 
trauma,  or  even  spontaneously.  Other  enlargements  of  the  spleen 
also  predispose  it  to  rupture.  This  occurrence  during  typhoid  fever 
is  rare,  and  usually  fatal.  Rupture  of  the  normal  spleen  usually  is  due 
to  severe  injury  directly  over  the  left  hypochondriac  region,  lower 
thorax  or  loin;  but  if  the  spleen  is  enlarged  it  may  be  ruptured  or  torn 
loose  from  its  supports  by  indirect  violence. 

Rupture  of  the  Kidney. — See  p.  1039. 

Rupture  of  the  Bladder. — See  p.  102G. 

Treatment. — If  there  is  reasonable  doubt  as  to  the  presence  of 
visceral  injury,  the  patient  should  be  carefully  studied  for  three  or 
four  hours  after  the  accident.  If  there  is  only  contusion  of  the  abdomi- 
nal wall,  distinct  improvement  usually  occurs  within  this  time.  If  no 
improvement  occurs,  I  believe  exploration  is  imperative,  even  if  the 
patient  does  not  seem  to  be  growing  worse.  The  mortality  without 
operation  is  96  per  cent.  The  earlier  the  operation  the  more  chance 
there  is  of  its  being  successful;  isolated  case  reports  show  that  the 
death  rate  after  operation  within  twenty  four  hours  of  injury  is  about 
55  per  cent.  The  general  mortality  after  operation,  in  consecutive 
series  of  cases,  is  about  85  per  cent.  (Meerwein,  1907).  Until  operation 
is  done,  the  shock  should  be  treated;  and,  after  making  a  diagnosis, 
morphin  may  be  administered  to  allay  pain.  In  cases  of  mere  con- 
tusion an  ice  bag  or  hot  water  bag  locally  may  be  soothing.  After 
operation,  treatment  as  for  peritonitis  is  indicated  (p.  861). 

Operation. — Unless  there  are  definite  indications  of  the  seat  of  the 
lesion,  a  left  paramedian  incision  should  be  made  just  below  the 
umbilicus.  Do  not  let  the  intestines  escape  from  the  wound.  If 
there  is  free  air  in  the  peritoneal  cavity,  or  if  gastric  or  intestinal 
contents  are  found,  it  is  clear  that  the  gastro-intestinal  tract  is 
ruptured.  If  the  abdomen  is  full  of  blood,  it  probably  comes  from  a 
solid  organ  or  from  the  omentum  or  mesenteries.  If  the  operation 
has  been  delayed,  the  presence  of  recent  adhesions,  lymph,  etc.,  will 
serve  as  a  guide  to  the  seat  of  rupture.  If  these  are  absent,  the  intes- 
tine must  be  examined  in  detail,  beginning  at  the  ileo-cecal  juncture, 
and  passing  upward  toward  the  duodenum.  Not  more  than  two  or 
three  feet  of  small  intestine  should  be  outside  the  abdomen  at  any 
one  time.  Most  ruptures  are  in  the  lower  ileum.  If  active  hemor- 
rhage is  found,  this  should  be  checked  before  anything  else  is  done. 
For  this  purpose  it  is  best  to  pack  all  the  intestines  away  first  to  one 
side  of  the  wound  and  then  to  the  other  and  examine  all  structures 
in  turn  on  the  right  and  on  the  left,  from  the  spinal  gutter  forward 
and  from  diaphragm  to  pelvis.  Eventration  of  the  intestinal  tube 
does  not  facilitate  the  search;  it  is  best  to  keep  the  intestines  inside 


INJURIES  OF  THE  ABDOMEN  895 

the  abdomen  as  much  as  possible.  Do  not  hesitate  to  make  your 
incision  large  enough  to  facilitate  rapid  operating. 

Intestinal  Tract. — A  rupture  of  the  antimesenteric  border  usually 
can  be  repaired  by  suture,  as  described  for  perforations  (p.  881); 
resection  of  the  intestine  should  be  avoided  if  possible.  A  complete 
transverse  rupture  should  be  treated  by  lateral  anastomosis,  or,  as 
a  last  resort,  and  only  when  the  rupture  is  low  in  the  intestinal  tract, 
by  establishment  of  a  false  anus.  At  the  duodeno-jejunal  juncture, 
where  lateral  anastomosis  is  impossible,  end-to-end  union  should  be 
attempted;  if  this  proves  impossible,  the  duodenal  end  should  be  closed, 
and  the  upper  end  of  the  jejunum  united  to  the  stomach  by  lateral 
anastomosis  (gastrojejunostomy,  p.  930).  In  Moynihan's  case  the 
regurgitation  of  the  bile  and  pancreatic  juice  into  the  stomach  caused 
no  disability.  Meerwein  successfully  supplemented  this  operation 
by  uniting  a  lower  loop  of  the  jejunum  to  the  descending  duodenum 
(anterior  antecolic  duodeno-jejunostomy).  If  the  intestine  is  torn 
loose  from  its  mesentery  at  any  point,  it  should  be  resected;  it  will 
be  best  then  to  fix  the  intestinal  loops  in  the  wound,  en  canon  de 
fusil  (p.  886),  after  ligating  their  ends  and  establishing  a  lateral  anasto- 
mosis, as  advised  in  cases  of  resection  for  strangulated  hernia.  Irriga- 
tion should  not  be  employed,  even  if  there  is  fecal  extravasation. 
A  large  rubber  or  glass  drainage  tube  should  be  carried  to  the  floor  of 
the  pelvis,  and  subsequent  treatment  should  be  conducted  as  in  cases 
of  peritonitis. 

Liver. — If  injury  of  the  liver  is  suspected,  the  incision  should  be 
made  through  the  upper  right  rectus.  As  the  blood-pressure  in  the 
liver  is  low,  hemorrhage  is  not  difficult  to  control  if  the  site  of  rupture 
is  accessible.  If  possible,  the  injury  should  be  sutured.  Mattress 
sutures  of  chromic  catgut  will  hold  in  most  cases,  if  they  are  not  drawn 
too  tightly.  If  tbey  cut  out,  they  should  be  tied  over  strands  of 
catgut,  used  as  the  quills  in  the  old-fashioned  quill  suture  (Fig.  107). 
If  direct  suture  proves  impossible,  the  omentum  may  be  sutured  into 
the  rupture,  as  a  tampon,  or  gauze  may  be  used.  Blood-clots  should 
be  scooped  out  of  the  pelvis  and  spinal  gutters,  or  wiped  up  with 
sponges;  but  irrigation  is  not  advisable.  The  pelvis  should  be  drained, 
and  subsequent  treatment  conducted  as  in  peritonitis.  The  mortality 
after  operation  is  from  75  to  80  per  cent.  (Boljarski,  1911). 

Spleen. — The  incision  is  best  made  in  the  upper  left  rectus  muscle. 
The  operative  mortality  is  about  38  per  cent.,  but  many  patients  die 
before  operation  can  be  undertaken.  If  the  spleen  is  not  much  dis- 
organized, it  may  be  possible  to  suture  the  rent,  or  to  tampon  it,  or 
even  to  compress  the  spleen  against  the  diaphragm  by  firmly  applied 
gauze  packs;  but  suture  is  difficult,  owing  to  the  friability  of  the  splenic 
pulp,  and  in  many  cases,  especially  if  the  lesion  is  at  all  extensive, 
splenectomy  (p.  1011)  should  be  done.  Sheldon  (1910),  as  the  result  of 
animal  experimentation,  advises  clamping  the  pedicle  of  the  spleen 
with  rubber-covered  forceps;  these  are  loosened  in  four  hours,  and 
if  ^hemorrhage  does  not  recur  they  are  subsequently  removed.     The 


890  ABDOMINAL  SURGERY  IN  GENERAL 

splenic  wound  itself  is  ignored.  This  method  is  more  applicable  to 
cases  of  stab  wound  than  to  rupture,  since  the  spleen  often  is  quite 
disorganized  in  the  latter  cases. 

Stab  Wounds  of  the  Abdomen. — The  symptoms  alone  are  not  suffi- 
ciently characteristic  to  warrant  a  diagnosis.  They  are  those  of  any 
abdominal  injury:  shock,  vomiting,  pain,  and  rigidity.  The  important 
question  to  decide  in  these  cases  is  whether  or  not  the  abdominal 
cavity  has  been  penetrated.  Under  no  circumstances  should  this 
be  left  in  doubt  until  the  development  of  peritonitis  renders  it  certain. 
The  question  as  to  which  viscus  is  injured  is  of  quite  secondary  impor- 
tance. If  protrusion  of  omentum,  prolapse  of  bowel,  or  escape  of  intes- 
tinal contents  renders  the  fact  of  penetration  certain,  no  hesitancy 
need  be  felt  in  freely  opening  the  peritoneal  cavity.  This  should  be 
done  by  a  para-median  incision. 

If  the  external  wound  is  small,  and  there  is  doubt  as  to  whether 
the  blade  actually  has  entered  the  peritoneal  cavity,  cautious  explora- 
tion should  be  undertaken.  The  wound  should  not  be  explored  by 
sound  or  finger.  It  should  be  stuffed  with  gauze  and  the  patient 
should  be  prepared  as  for  an  abdominal  operation.  The  surgeon 
should  then  dissect  down  layer  by  layer  and  thus  follow  the  tract 
of  the  wound.  If  difficulty  is  experienced  in  tracing  a  small  stab 
wound,  it  is  best  first  to  lay  bare  the  abdominal  aponeurosis  (sheath 
of  rectus,  aponeurosis  of  external  oblique)  over  a  wide  area,  and 
search  it  for  the  stab  wound.  If  this  cannot  be  found,  and  it  is  known 
that  the  blade  was  very  short  (that  of  a  pen-knife,  for  example),  and 
if  there  are  no  other  symptoms  of  penetration,  the  skin  incision  may 
now  be  closed.  If,  however,  it  be  ascertained  that  the  blade  has  pene- 
trated the  aponeurosis,  the  surgeon  should  next  lay  bare  the  trans- 
versalis  fascia  and  peritoneum,  but  should  not  open  the  latter  until 
he  is  sure  it  has  been  penetrated.  I  am  thus  insistent  upon  this  cautious 
approach  to  the  peritoneal  cavity,  when  the  fact  of  its  penetration 
is  in  doubt,  because  it  often  happens  on  opening  the  abdomen  widely 
in  these  cases  that  inspection  shows  no  evidence  of  intra-abdominal 
lesion,  and  very  extensive  search  becomes  necessary  to  exclude  the 
possibility  of  visceral  injury;  and  if  none  be  found  to  exist,  and  it 
is  shown  that  the  vulnerating  weapon  itself  never  had  opened  the 
peritoneal  cavity,  the  surgeon  will  have  subjected  his  patient  to  a 
quite  unnecessary  and  by  no  means  trivial  operation.  If,  however, 
the  fact  of  abdominal  penetration  has  been  determined  by  the  method 
just  described,  the  surgeon  will  be  quite  justified  in  his  extensive 
intra-abdominal  manipulations,  even  though  no  lesion  be  found  more 
serious  than  hemorrhage  from  an  omental  vein  (Deaver  and  Ashhurst). 

If  some  of  the  abdominal  contents  protrude  through  a  wound 
their  condition  will  determine  their  proper  treatment.  If  viable,1 
they  should  be  cleansed,  any  visceral  wounds  should  be  repaired, 
and  the  viscera  should  be  replaced.    For  this  purpose  it  may  be  neces- 

1  See  Strangulated  Hernia,  p.  829. 


INJURIES  OF  THE  ABDOMEN  897 

sary  to  enlarge  the  abdominal  wound.  Omentum  which  protrudes 
from  an  abdominal  wound  should  be  excised,  as  should  portions  of 
prolapsed  intestine  which  appear  certain  to  become  gangrenous. 

The  abdominal  structures  most  often  wounded  are  the  following: 
small  intestine,  colon,  omentum  or  mesenteries,  liver,  stomach,  and 
diaphragm. 

After  opening  the  abdomen,  the  first  thing  to  do  is  to  control  hemor- 
rhage. Each  intestinal  lesion  should  be  repaired  as  it  is  discovered, 
and  should  not  be  put  aside  with  the  idea  of  repairing  it  later  in  the 
operation.  Careful  search  of  the  entire  intestinal  tract  is  necessary, 
as  the  lesions  often  are  multiple,  and  in  about  one-third  of  the  cases 
which  terminate  fatally  postmortem  examination  shows  this  result 
to  be  due  to  the  presence  of  one  or  more  perforating  wounds  which 
were  not  discovered  at  operation.  The  general  mortality  after  opera- 
tion is  about  50  per  cent.;  it  is  much  higher  if  no  operation  is  done. 
When  operation  is  done  within  the  first  twenty-four  hours  the  mortality 
is  less  than  10  per  cent. 

Gunshot  Wounds  of  the  Abdomen. — In  addition  to  the  general 
account  of  these  injuries  given  in  Chapter  VII,  some  more  particular 
account  of  the  operative  treatment  may  be  given  in  this  place.  The 
probability  of  penetration  is  so  great  that  every  case  should  be 
subjected  to  exploratory  laparotomy  at  as  early  an  hour  as  possible. 
The  incision  should  be  made  close  to  the  median  line,  in  that  portion 
of  the  abdomen  injured.  The  wound  of  entrance  of  the  bullet  may  be 
disregarded,  unless  there  is  hemorrhage  through  it  from  a  vessel  in 
the  abdominal  wall ;  then  the  wound  of  entrance  should  be  opened  and 
the  bleeding  arrested.  But  it  is  much  better  to  enter  the  abdomen 
through  healthy  structures,  and  at  the  most  convenient  point,  than 
to  make  the  exploration  through  the  infected  bullet  tract.  The  bullet 
wound,  however,  should  be  swabbed  out  with  iodin  (3  per  cent.) 
and  packed  with  gauze.     In  warfare  the  tract  is  debrided. 

Gunshot  wounds  of  the  intestinal  tract  usually  are  perforating,  the 
bullet  producing  wounds  of  entrance  and  exit  in  each  coil  of  intes- 
tine which  it  injures.  Sometimes  as  many  as  four  or  six  perforations 
will  be  found  within  a  few  centimeters  of  each  other  in  one  coil  of  bowel. 
In  such  cases  it  may  be  necessary  to  excise  the  segment  of  gut  wounded ; 
but  whenever  possible  suture  should  be  preferred,  and  even  if  the 
repair  of  the  perforations  by  suture  seems  to  cause  some  obstruction 
to  the  lumen  of  the  gut,  I  believe  it  is  better  to  run  this  risk  than  to 
undertake  resection.  The  omentum  may  be  sutured  over  the  damaged 
area,  to  reinforce  the  sutured  perforations;  or  the  damaged  coil  of  bowel 
may  be  fixed  in  the  wound,  to  preclude  damage  from  intraperitoneal 
leakage  of  intestinal  contents,  if  there  is  doubt  about  the  sutures 
holding.  If  the  mesentery  is  so  much  damaged  as  to  impair  the 
vitality  of  a  segment  of  intestine,  resection  can  hardly  be  avoided. 
Each  lesion  should  be  repaired  as  it  is  found ;  it  is  only  a  waste  of  time 
to  pass  over  a  perforation  thinking  to  find  and  repair  it  at  a  later 
stage  of  the  operation. 


S<)S  ABDOMINAL  SURGERY  IN  GENERAL 

Gunshot  wounds  of  the  stomach  require  special  mention.  The 
"head-high"  (reversed  Trendelenburg)  posture,  with  a  sand  bag 
under  the  patient's  lower  dorsal  spine,  is  a  great  help  in  exposing  the 
field  of  operation.  The  stomach  is  best  found  by  identifying  first 
the  left  lobe  of  the  liver,  and  passing  the  fingers  from  its  under  surface 
over  the  gastro-hepatic  omentum  on  to  the  anterior  wall  of  the 
stomach.  Usually  there  is  both  a  wound  of  entrance  and  one  of  exit. 
The  wound  first  found  should  be  repaired  at  once.  If  no  other  wound 
is  found  on  the  anterior  wall,  the  gastro-colic  omentum  should  be 
divided,  between  hemostats,  on  the  colonic  side  of  the  gastro-epiploic 
arteries,  and  for  a  distance  at  least  of  8  cm.  The  existence  of  a  per- 
foration on  the  posterior  wall  usually  will  be  indicated  by  extrava- 
sation within  the  lesser  peritoneal  cavity.  W.  Martin  (1907)  found 
that  among  the  cases  he  studied  failure  to  suture  the  bullet-hole  in 
the  posterior  gastric  wall  had  not  materially  influenced  the  mortality. 
A  perforation  should  be  sutured  if  found;  if  inaccessible  from  the 
posterior  wall  of  the  stomach  the  surgeon  may  open  the  anterior  wall 
of  this  organ  and  suture  the  posterior  perforation  from  inside  the 
stomach.  If  more  room  is  required  to  expose  a  perforation  in  the 
cardiac  region  of  the  stomach,  temporary  resection  of  the  costal 
margin  may  be  adopted;  if  the  line  of  section  is  kept  in  the  cartilages 
(not  invading  the  bony  structure  of  the  ribs) ,  the  pleural  cavity  will 
not  be  opened  (Auvray).  Drainage  of  the  lesser  peritoneal  cavity 
should  be  secured  by  a  wick  of  gauze  emerging  through  the  gastro- 
colic omentum;  hemorrhage  from  this  structure,  which  has  been  con- 
trolled during  operation  by  hemostats,  is  permanently  arrested  by 
suture.  Drainage  through  the  left  loin  seldom  is  required;  but  some 
form  of  drainage  of  the  lesser  peritoneal  cavity  never  should  be 
neglected,  particularly  in  cases  where  the  pancreas  has  been  injured. 
Another  drain  should  be  placed  anterior  to  the  stomach,  and  in 
cases  where  gastric  or  intestinal  contents  have  been  diffused  in  the 
abdomen,  the  pelvis  should  be  drained  also  through  a  suprapubic 
opening. 

Gunshot  wounds  of  the  duodenum  are  rare,  scarcely  ever  uncompli- 
cated by  other  lesions,  and  usually  fatal.  Proper  exposure  is  difficult 
and  it  may  be  impossible  to  suture  or  even  to  discover  a  perforation 
on  the  retroperitoneal  surface.  Usually  it  will  be  well  to  drain  the 
sutured  area,  especially  if  it  is  retroperitoneal.  Drainage  always  should 
be  employed,  preferably  through  the  loin,  if  a  retroperitoneal  perfora- 
tion is  suspected  but  not  definitely  located,  or  if  one  is  located  in 
an  inaccessible  position.  Resection  with  end-to-end  anastomosis  may 
be  required.  In  many  instances  it  probably  will  be  safer  to  close 
both  ends  of  the  duodenum,  and  do  gastrojejunostomy  or  duodeno- 
jejunostomy (Deaver  and  Ashhurst,  1909). 

Gunshot  wounds  of  the  liver  often  bleed  profusely.  There  usually 
is  little  difficulty  in  checking  bleeding  by  suture  or  tampon,  and  if 
hemorrhage  is  arrested  in  good  time,  the  immediate  prognosis  is 
reasonably  good;  though  secondary  complications,  such  as  hepatic 


INJURIES  OF  THE  ABDOMEN  899 

or  subphrenic  abscess,  empyema,  or  pneumonia,  are  much  to  be 
feared.  The  general  mortality  after  operation  is  from  35  to  40  per 
cent.;  in  a  series  of  37  cases  uncomplicated  by  injuries  of  other 
viscera,  the  mortality  was  only  16  per  cent.  (Patel  and  Loaec,  1912). 

Gunshot  wounds  of  the  spleen,  as  in  the  case  of  subcutaneous 
injuries,  frequently  cause  so  much  disorganization  as  to  require 
splenectomy. 

Gunshot  wounds  of  the  pancreas  almost  always  are  complicated 
by  injuries  of  surrounding  viscera.  The  best  exposure  is  gained 
through  the  gastro-colic  omentum,  or  between  great  omentum  and 
transverse  colon.  Tamponade  is  more  successful  than  attempts  at 
suture.  Drainage  always  should  be  employed.  If  the  injury  is  undis- 
covered, death  is  practically  certain.  •  The  death  rate  after  operation 
is  about  43  per  cent.  (Diehl,  1911). 


CHAPTER  XXIII. 
SURGERY  OF  THE  GASTRO-INTESTINAL  TRACT. 

SURGERY  OF  THE  APPENDIX  VERMIFORMIS. 

Appendicitis. — Inflammation  of  the  vermiform  appendix  of  the 
cecum  is  the  most  frequent  form  of  abdominal  disease  seen  by  the 
surgeon.  Its  symptoms  were  described  even  by  authors  of  classic 
times;  but  no  one,  except  perhaps  Melier,  in  1827,  considered  disease 
of  the  vermiform  process  as  the  chief,  if  not  the  sole  cause  of  these 
symptoms  until  it  was  proved,  about  thirty-five  years  ago,  by  Matter- 
stock  in  Germany  that  almost  all  abscesses  in  the  right  iliac  fossa 
were  associated  with  a  perforated  appendix;  and  by  Fitz  in  America 
that  in  cases  of  so-called  typhlitis  (inflammation  of  the  cecum)  and 
in  cases  of  appendicitis  the  symptoms  were  identical.  The  term 
appendicitis  was  introduced  by  Fitz  in  1886. 

Pathogenesis. — The  anatomy  of  the  appendix  predisposes  it  to 
inflammation.  It  is  filled  with  fecal  matter  charged  with  bacteria; 
it  contains  a  long  mucous  canal  which  opens  by  a  narrow  orifice  into 
the  cecum;  usually  it  is  more  or  less  kinked  or  twisted,  owing  to  the 
shape  of  its  mesentery;  and  the  slightest  swelling  of  its  walls  at  any 
point  may  cause  complete  obliteration  of  its  lumen,  converting  its 
distal  segment  into  a  closed  cavity  whose  naturally  infectious  con- 
tents are  thus  markedly  increased  in  virulence.  In  addition  to  these 
factors,  the  appendix  possesses  a  precarious  blood-supply :  it  possesses 
no  collateral  circulation;  its  arteries  are  "end-arteries;"  and  the 
slightest  swelling  or  constriction  or  kinking  of  the  organ  may  cut 
off  the  blood-supply  completely,  resulting  in  partial  or  total  necrosis. 

The  infection,  in  the  vast  majority  of  cases,  is  enterogenous;  but 
hematogenous  infection  sometimes  occurs  (p.  902).  In  enterogenous 
infection  the  bacteria  swarming  in  the  fecal  contents  of  the  appendix 
produce  a  sub-epithelial  reaction,  which  is  known  as  the  primary 
focus  (Primarinfekt)  of  Aschoff  (1908).  This  occurs  in  the  depths  of 
one  of  the  mucous  crypts  of  the  appendix,  and  consists  of  a  collection 
of  neutrophile  leukocytes.  The  epithelium  itself,  which  overlies  the 
primary  focus,  may  be  destroyed  very  early  in  the  process,  its  place 
being  taken  by  a  plug  of  fibrin.  Usually  a  number  of  these  primary 
foci  develop  simultaneously.  The  inflammatory  reaction  spreads  very 
quickly  toward  the  serous  coat  of  the  appendix,  and  peritonitis  may 
develop  before  the  mucous  surface  is  seriously  diseased.  In  almost 
every  case,  the  primary  infection  is  due  to  the  streptococcus;  but 
invariably  the  colon  bacillus  invades  the  walls  of  the  organ  secondarily, 
(900) 


APPENDICITIS  901 

and  soon  over-grows  the  streptococcus,  so  that  cultures  of  the  latter 
are  lost. 

If  resolution  does  not  occur  at  this  very  early  stage  of  appendicitis, 
these  intramural  foci  become  confluent,  and  the  condition  is  known  as 
simple  phlegmonous  appendicitis.  The  existence  of  a  primary  catarrhal 
appendicitis,  with  ulceration  as  its  result,  is  denied  by  Aschoff;  what 
was  formerly  described  as  catarrhal  appendicitis  is  now  recognized 
as  phlegmonous  (intramural)  in  nature.  This  phlegmonous  stage  is 
present,  with  few  exceptions,  whenever  the  disease  has  lasted  more 
than  twelve  hours.  Even  should  resolution  occur  at  this  early  stage  of 
the  disease,  the  appendix  will  not  return  to  its  normal  state;  cicatricial 
tissue  remains,  strictures  may  form,  and  the  organ  is  more  than  ever 
predisposed  to  infection.  If  resolution  does  not  occur  early  in  the 
phlegmonous  stage  of  the  disease,  intramural  abscesses  develop, 
miliary  in  size.  These  are  prone  to  perforate  the  serous  coat  of  the 
appendix  (miliary  perforations),  causing  peritonitis  without  macro- 
scopic perforation  of  the  appendix.  Or  they  may  rupture  into  the 
lumen  of  the  appendix,  producing  ulcers.  Ulcerative  appendicitis 
never  is  the  primary  stage;  it  follows  the  phlegmonous,  whether  or 
not  this  has  progressed  to  the  stage  of  suppuration.  In  this  ulcerative 
stage  the  mucous  membrane  frequently  is  hemorrhagic;  but  the  most 
serious  complications  of  this  stage  are  (1)  ulcerative  perforation  (macro- 
scopic), which  usually  occurs  on  the  antimesenteric  border  of  the 
appendix;  and  (2)  necrosis  of  the  wall  of  the  appendix.  This  necrosis 
may  be  the  result  of  anemia  from  vascular  thrombosis,  or  it  may  be 
due  to  the  direct  toxic  influence  of  bacteria  on  the  appendicular  wall. 
In  either  case  secondar}'  invasion  of  the  necrotic  area  b}^  putrefactive 
microbes  (from  the  fecal  contents  of  the  appendix)  leads  to  gangrene. 
Separation  of  the  slough  formed  in  this  manner  produces  yet  another 
variety  of  perforation. 

Every  attach  of  appendicitis  passes  through  all  the  stages  described 
unless  arrested  spontaneously  or  unless  the  appendix  is  removed. 

If  resolution  occurs  early  in  the  phlegmonous  stage  of  the  disease, 
and  if  the  appendix  suffers  a  number  of  such  mild  attacks  (which  may 
be  so  mild  as  to  pass  unnoticed),  a  condition  described  as  chronic 
appendicitis  may  develop.1  This  term  implies  not  so  much  a  chronic 
inflammation,  as  defined  at  p.  35,  as  it  does  the  result  of  previous 
inflammatory  attacks.  The  lesions  are  fibrotic  and  sclerotic  in  nature, 
and  are  most  marked  in  the  distal  portion  of  the  appendix,  especially 
behind  a  stricture.  In  some  cases  repeated  mild  attacks  lead  to 
obliteration  of  the  lumen  of  the  organ,  through  the  process  of  adhesion 
between  its  apposed  granulating  walls.  This  appendicitis  obliterans 
(Senn,  1894)  usually  affects  only  the  tip  of  the  organ,  but  as  the  patient 
ages  the  entire  lumen  may  be  obliterated. 

1  This  is  the  teaching  of  Aschoff,  whose  studies  of  the  pathology  of  appendicitis 
are  the  most  recent  and  accurate.  Other  authorities  have  held  that  an  acute 
attack  seldom  occurs  except  in  an  appendix  already  the  seat  of  chronic  appendicitis. 
Both  views  are  harmonized  if  we  admit  that  chronic  appendicitis  always  begins 
with  a  definite  attack  which  is  acute  pathologically,  no  matter  how  mild  clinically. 


902     SURGERY  OF  THE  G ASTRO-INTESTINAL  TRACT 

Strictures,  or  actual  occlusion  of  the  lumen  of  the  appendix  may 
occur  at  various  points.  If  a  stricture  only  is  present,  it  is  usual  for 
a  coprolith  or  fecal  concretion  to  develop  behind  it  (Fig.  921),  or 
between  two  strictures.  If  complete  occlusion  exists  the  tip  of  the 
appendix  beyond  the  occlusion  or  the  segment  lying  between  two 
occluded  points  may  become  the  seat  of  an  empyema,  during  an  acute 
attack;  or  if  the  infection  dies  out  a  cyst  may  succeed  the  empyema. 
Not  infrequently  in  an  acute  attack  temporary  occlusion  (from  edema 
or  kinking)  occurs  close  to  the  cecum  and  the  whole  appendix  is  con- 
verted into  an  abscess  sac.  Fecal  concretions  found  in  the  appendix 
at  operation  almost  surely  are  the  result  of  a  previous  attack  of 
appendicitis;  after  they  are  once  formed  they  predispose,  by  their 
mechanical  action,  to  further  attacks  and  especially  to  perforation, 
which  occurs  oftenest  behind  the  concretion.  Foreign  bodies  which 
are  rare  in  the  appendix,  act  in  much  the  same  way  as  do  the  fecal 
concretions:  they  may  lie  in  the  lumen  of  the  appendix  for  years 
without  producing  any  symptoms. 


Fig.  921.  —  Gangrenous  appendix  with  fecal  concretion  near  tip.  Note  thickness 
of  walls,  indicating  previous  attacks;  stricture  on  proximal  side  of  concretion;  and 
impending  perforation  near  tip.     Episcopal  Hospital. 

Causes. — Appendicitis  is  commonest  between  the  ages  of  ten  and 
thirty  years,  when  all  infectious  disorders  are  most  prevalent.  Strep- 
tococci, especially  diplococci,  are  the  bacteria  most  often  directly 
responsible  for  an  attack  of  the  disease;  but  why  it  is  that  they  produce 
the  attack  at  any  given  time  is  a  mystery.  The  great  frequency  of 
enterogenous  infection  has  already  been  noted;  and  it  is  probable  that 
stagnation  of  the  contents  of  the  appendix  from  kinking  is  the  main 
predisposing  cause.  Digestive  derangements  increase  the  virulence 
of  bacteria  in  the  intestinal  canal,  or  are  the  result  of  this  increased 
virulence ;  and  disordered  peristalsis  may  force  fecal  matter  containing 
these  highly  virulent  organisms  into  the  appendix.  There  is  no  good 
proof  that  appendicitis  arises  as  the  extension  into  the  appendix  of  a 
catarrhal  inflammatory  process  in  the  cecum.  It  is  probable  that  intes- 
tinal parasites  found  in  the  appendix  (Fig.  922)  have  no  etiological 
significance  except  as  any  other  foreign  bodies. 

In  some  cases  it  is  possible  that  infection  occurs  through  the  blood- 
stream (hematogenous).  In  this  connection  attention  has  been  called 
(by  Kellynack,  Kretz,  and  others)  to  the  histological  resemblance  of 
the  appendix  to  the  faucial  tonsils,  both  of  them  containing  much 
lymphoid  tissue ;  and  it  has  been  held  that  appendicitis  is  an  abdominal 
angina.  But  neither  the  clinical  history  of  the  patients,  nor  the 
histological  examination  of  the  diseased  appendices  supports  the  theory 


APPENDICITIS  903 

of  hematogenous  infection,  except  in  rare  instances.  Rosenow  (1915) 
has  shown,  however,  that  certain  strains  of  streptococci  have  an 
affinity  for  different  organs;  and  it  may  well  be  that  hematogenous 
infection  of  all  organs  is  more  frequent  than  generally  recognized. 

One  attack  of  appendicitis  predisposes  to  another.    Nearly  85  per 
cent,  of  3000  patients  under  Deaver's  care  had  had  a  previous  attack. 


Fig.  922. — Acute  appendicitis,  appendix  containing  oxyuris  vermicularis.    (Natural 
size.)     Episcopal  Hospital. 

Acute  Appendicitis. — Symptoms  and  Clinical  Course. — Pain,  nausea, 
and  vomiting  followed  by  tenderness  and  rigidity:  These  are  the 
cardinal  symptoms  of  acute  appendicitis.  Usually  without  previous 
warning  the  patient  develops  a  sudden  colicky  pain,  more  or  less 
diffused  throughout  the  abdomen  or  localized  to  the  umbilical  region. 
This  pain  is  due  to  the  disordered  peristaltic  action  of  the  appendix 
in  attempts  to  empty  itself  against  resistance.  It  is  analogous  to  the 
pain  of  biliary,  intestinal,  or  renal  colic;  like  them  it  excites  nausea 
and  vomiting.  The  vomiting  is  reflex,  and  suffices  only  to  empty  the 
stomach.  It  is  not  repeated  unless  peritonitis  develops,  when  it 
assumes  the  type  already  described  at  p.  857.  This  primary  nausea 
and  vomiting  follows  and  does  not  precede  the  initial  pain  of  appen- 
dicitis; to  this  rule  there  are  very  few  exceptions.  At  this  time  there 
is  no  special  tenderness  in  the  abdomen;  indeed,  as  in  intestinal  colic, 
pressure  may  relieve  the  pain.  But  usually  within  twelve  hours  the 
character  of  the  pain  changes;  it  is  no  longer  diffuse  and  colicky,  but 
becomes  localized  to  the  right  iliac  region,  where  the  diseased  appendix 
is  found.  The  pain  is  now  burning,  constant,  and  intense.  Simul- 
taneously with  this  localization  of  the  pain  to  the  right  iliac  fossa 
there  develop  both  tenderness  and  rigidity,  which  also  are  confined 
to  the  region  of  the  appendix.  Palpation  now  reveals  a  normal 
abdomen  elsewhere,  but  over  the  right  iliac  fossa  the  muscles  (par- 
ticularly the  right  rectus)  are  rigid,  and  tenderness  is  so  marked  that 
even  slight  pressure  causes  extreme  pain.  This  localized  rigidity  is 
the  most  important  single  symptom  of  appendicitis.  Roughly  speaking, 
all  these  symptoms  of  appendicitis  are  localized  around  McBurney's 
point,  which  was  described  by  its  author  in  1891  as  a  point  from  one 
and  a  half  to  two  inches  (4  to  5  cm.)  distant  from  the  anterior  superior 
spine  of  the  right  ilium  on  a  line  drawn  between  this  spine  and  the 
umbilicus. 

When  this  stage  of  the  disease  has  been  reached,  it  is  possible  in  all 
but  the  most  exceptional  cases  to  make  an  accurate  diagnosis  of  appen- 
dicitis.    The  condition  is  clinically  one  of  localized  peritonitis,  as 


'.Hi  I  SURGERY  OF  THE  G ASTRO-INTESTINAL   TRACT 

described  at  p.  857,  and  that  this  is  the  pathological  state  is  evident 
from  the  account  of  the  pathogenesis  of  appendicitis  already  given. 
Appendicitis  is  localized  peritonitis;  all  the  signs  of  this  condition  are 
present :  tenderness  and  rigidity,  arrest  of  peristalsis  in  the  immediate 
vicinity  of  the  lesion,  local  tympany  from  paresis  and  distention  of 
the  ileo-cecal  coil  of  the  intestinal  canal;  and  persistent  constipation. 
The  development  of  complications  should  not  he  awaited  before 
making  an  accurate  diagnosis. 

In  a  small  proportion  of  cases  the  attack  does  not  begin  with  acute 
pain,  but  with  a  gradually  increasing  discomfort  in  the  neighborhood 
of  the  appendix;  and  in  such  cases,  the  physical  signs  of  appendicitis 
often  develop  without  any  nausea  or  vomiting.  Hence  it  is,  that  in 
appendicitis  as  in  all  other  acute  abdominal  lesions  when  the  history 
of  the  case  is  atypical,  it  is  safer  to  rely  on  the  physical  examination 
than  on  the  history,  in  reaching  a  diagnosis. 

No  mention  has  been  made  hitherto  of  the  temperature,  pulse,  or 
leukocytosis,  in  connection  with  appendicitis.  They  are  of  quite 
secondary  importance.  Usually  the  temperature  is  slightly  elevated 
from  the  first,  and  the  pulse  quickened,  as  in  all  febrile  states.  There 
also  is  leukocytosis  in  most  cases,  the  white  blood  cells  numbering 
anywhere  from  10,000  to  40,000.  The  white-blood  count  is  of  more 
value  in  prognosis  (p.  911)  than  in  diagnosis. 

When  the  stage  of  localized  symptoms  described  above  has  been 
reached,  the  disease  pursues  either  one  of  two  courses:  It  subsides, 
or  complications  develop.  In  the  former  case  the  pain  gradually 
lessens;  the  tenderness  changes  to  mere  "soreness,"  rigidity  disappears, 
flatus  is  passed  normally,  the  temperature  curve  reaches  the  normal, 
and  the  leukocytosis  gradually  subsides.  The  course  of  such  an 
attack  lasts  on  the  average  from  three  days  to  a  week.  If  the  attack 
does  not  subside,  complications  develop;  they  are  frequent  and  almost 
countless.  Among  the  more  important  are  perforation  and  gangrene 
of  the  appendix,  and  abscess  formation  or  diffuse  peritonitis  with 
all  its  dire  consequences.  The  symptoms,  diagnosis,  and  treatment 
of  these  complications  are  considered  at  p.  909. 

Diagnosis.  —  The  diagnosis  of  appendicitis  usually  is  easy.  It  is 
the  most  frequent  of  all  acute  abdominal  diseases,  and  should  be  ever 
in  the  surgeon's  mind.  In  intestinal  colic  the  pain  is  general  and  does 
not  become  localized  to  the  region  of  the  appendix;  pressure  relieves 
it;  nausea  and  vomiting  are  by  no  means  constant,  and  often  precede 
the  onset  of  the  pain;  active  peristalsis  is  audible;  and  diarrhea  is  the 
usual  outcome.  At  no  period  of  the  attack  is  there  muscular  rigidity. 
Fever  is  unusual.  Leukocytosis  is  absent.  In  biliary  colic  the  pain 
is  situated  in  the  right  hypochondrium  and  often  radiates  to  the 
right  shoulder.  A  history  of  many  previous  attacks  often  is  obtainable, 
and  jaundice  may  have  been  present  at  some  time.  Tenderness  and 
rigidity  if  present  are  confined  to  the  gall-bladder  area.  If  the  patient 
is  past  forty  years  of  age  the  attack  probably  is  biliary,  not  appen- 
dicular. In  acute  cholecystitis  the  symptoms  somewhat  resemble  those 
of  biliary  colic.     Tenderness  and  rigidity  are  constant,  but  are  con- 


APPENDICITIS  905 

fined  to  the  upper  right  abdominal  quadrant,  unless  the  gall-bladder 
is  displaced.  The  characteristics  by  which  an  enlarged  gall-bladder  is 
recognized  are  stated  at  p.  976.  In  renal  colic  from  disease  of  the 
right  kidney,  the  symptoms  may  closely  simulate  those  of  appen- 
dicitis, particularly  when  a  calculus  is  lodged  in  the  ureter.  Yet  the 
radiation  of  the  pain,  the  urinary  findings,  and  the  absence  of  gastro- 
intestinal symptoms  suffice  in  most  cases  to  make  the  diagnosis  clear. 
Skiagraphy  is  a  valuable  aid.  In  acute  salpingitis,  especially  affecting 
the  right  tube,  the  peritoneal  symptoms  are  confined  to  the  pelvis 
and  gastro-intestinal  symptoms  are  absent.  Tenderness  is  too  low 
and  too  near  the  median  line,  for  appendicitis;  it  is  not  at  McBurney's 
point,  but  about  over  the  middle  of  Poupart's  ligament.  Vaginal 
examination  confirms  the  diagnosis.  Some  cases  of  typhoid  fever 
begin  with  rather  acute  abdominal  pain,  and  this  may  be  accompanied 
by  nausea  and  vomiting.  Usually,  however,  strict  inquiry  reveals 
that  the  actual  onset  of  the  disease  occurred  several  days  previously, 
with  malaise,  headache,  feverishness,  etc.  The  temperature  is  too 
high  (103°  F.  or  more)  and  the  pulse  too  slow  (100  or  lower)  for 
appendicitis;  and  there  is  leukopenia  not  leukocytosis. 

In  none  of  the  affections  mentioned,  nor  in  any  of  the  score  or  more 
other  diseases  which  may  be  exceptionally  confused  with  appendicitis, 
is  the  clinical  history  typical  of  the  latter:  sudden  pain,  first  diffuse, 
then  settling  to  the  right  iliac  fossa;  followed  by  vomiting;  and  the 
extremely  important  localized  tenderness  and  rigidity. 

Prognosis.  —  The  appendix  is  the  fons  et  origo  mail,  and  if  it  is 
removed  before  complications  develop,  the  prognosis  is  brilliant. 
The  mortality  of  operation  at  this  stage  of  the  disease  is  so  low  that 
hundreds  and  hundreds  of  such  simple  cases  are  cured  without  a  death. 
Once  in  several  hundrecf  operations  it  may  happen  that  a  patient  dies 
of  pneumonia  or  some  other  unforeseen  complication;  but  this  minimal 
risk  stands  in  no  sort  of  relation  with  the  risk  run  by  delaying  operation 
to  determine  whether  or  not  complications  are  about  to  develop. 
As  a  matter  of  fact,  even  under  the  most  approved  non-operative  treat- 
ment, complications  develop  in  at  least  10  per  cent,  of  cases.  It  was 
justifiable  to  delay  operation  only  in  the  days  before  the  develop- 
ment of  aseptic  surgery;  until  that  time  the  only  form  of  intra-abdomi- 
nal disease  successfully  amenable  to  surgical  treatment  was  localized 
suppuration.  It  was  then  and  it  is  now  absolutely  impossible  to 
control  the  course  of  the  disease  in  the  appendix  by  any  means  known 
to  medical  science.1  Unless  the  appendix  is  removed  the  patient  is 
left  to  the  unaided  efforts  of  nature.  Never  should  the  surgeon  call 
for  aid  from  beneficent  Nature  until  he  has  exhausted  his  own 
resources.  Apollo  would  not  help  the  teamster  until  the  latter  had 
whipped  up  his  horses  and  put  his  own  shoulder  to  the  wheel.  The 
mere  diagnosis  of  appendicitis  should  be  an  indication  for  immediate 
operation.  I  am  conceited  enough  to  believe  that  I  can  recognize, 
as  well  as  anyone  else,  the  occurrence  of  perforation  or  suppuration 

1  I  am  speaking  of  disease  in  the  appendix,  not  of  the  peritoneal  complications 
of  this  disease. 


906 


SURGERY  OF   THE  GASTROINTESTINAL  TRACT 


in  appendicitis,  but  I  frankly  confess  my  utter  inability  to  feel  sure 
one  hour  that  neither  of  these  events  will  occur  during  the  next,  so 
long  as  an  acutely  inflamed  appendix  remains  within  a  patient's  belly. 
It  is  possible  to  argue  on  probabilities,  and  to  defer  operation  in  cases 
that  appear  mild;  but  sooner  or  later  the  surgeon  will  encounter  a 
case  which  will  make  him  regret  his  procrastination,  and  will  convince 
him  that  he  has  lost  the  life  of  his  patient  through  over-confidence 
in  his  own  powers  of  prognostication.  Even  if  life  be  not  lost,  it 
will  be  surely  jeopardized  by  the  development  of  peritonitis,  localized 
or  diffused,  with  the  possibility  of  its  lethal  sequels,  such  as  gangrene 
of  the  bowel,  intestinal  obstruction,  pylephlebitis,  etc.  It  is  strange 
that  well-meaning  physicians,  and  even  some  apparently  intelligent 
surgeons  will  delay  operation,  trusting  to  be  warned  of  impending 
danger  by  well-defined  symptoms  in  time  to  employ  an  operation, 
when  the  best  time  for  operation  is  before  alarming  symptoms  arise. 
Only  in  the  very  aged,  or  in  those  with  extremely  serious  visceral  lesions 
(cardiac  or  renal)  is  delay  justifiable. 

Treatment.  —  The  abdomen  should  be  shaved  and  cleansed  and 
the  bladder  emptied  (by  catheter  if  necessary)  as  before  any  abdominal 
operation.  No  other  preparation  is  required,  but  in  many  cases  it  is 
well  to  empty  the  lower  bowel  by  enema. 

Operation. — I  prefer,  and  habitually  employ,  the  transverse  incision 
of  G.  G.  Davis1  (1906).     Other  incisions  for  appendectomy  have  been 

described  in  Chapter  XXII.  This 
transverse  incision  is  so  planned 
that  its  center  lies  over  the  right 
semilunar  line,  at  the  level  of  the 
anterior  superior  spine  of  the  ilium. 
In  simple  acute  cases  the  incision  is 
from  4  to  5  cm.  long  (Fig.  923).  The 
skin  and  subcutaneous  tissues  are 
divided,  exposing  the  aponeurosis 
of  the  external  oblique.  This,  and 
the  anterior  sheath  of  the  rectus  are 
incised  in  the  same  transverse  direc- 
tion throughout  the  inner  half  of 
the  wound.  The  muscle  fibers  of  the 
rectus  are  thus  exposed,  and  are  to 
be  retracted  toward  the  midline. 
In  this  way  the  posterior  sheath  of 
the  rectus  and  the  transversalis 
fascia  are  exposed.  The  peritoneal 
cavity  is  next  opened  in  the  usual  way,  in  a  transverse  direction.  The 
left  forefinger  is  then  inserted  into  the  peritoneal  cavity,  and  hooks 
up  the  abdominal  wall  on  the  outer  side  of  the  opening  already  made. 
With  closed  blunt  scissors  the  operator  then  splits  the  internal  oblique 

1  Similar  incisions  were  described  by  J.  W.  Elliott  (1896),  A.  E.  Rockey  (1905), 
and  Chaput  (1905). 


Fig.  923. — Transverse  incision  for 
appendectomy;  two  weeks  after  opera- 
tion.    Episcopal  Hospital. 


APPENDICITIS  907 

and  transversalis  muscles  outward  in  the  direction  of  their  fibers  (which 
here  run  directly  transversely),  thus  passing  parallel  to  the  motor 
nerves  of  the  abdominal  wall.  The  transversalis  fascia  and  perito- 
neum are  then  cut  in  the  same  direction,  throughout  the  whole  extent 
of  the  wound.  If  more  room  is  needed  toward  the  median  line,  the 
anterior  and  posterior  sheaths  of  the  rectus  may  be  incised  as  far  as 
the  linea  alba,  but  the  muscle  itself  need  not  be  cut,  as  it  can  be 
drawn  far  to  the  left  with  a  retractor.  If  more  room  is  needed  to  the 
outer  side,  the  oblique  and  transversalis  muscles  may  be  cut  as  far 
as  the  iliac  spine,  or  further  if  necessary,  without  any  damage  to  the 
abdominal  nerves  (Fig.  931).  Some  branches  of  the  deep  circumflex 
iliac  artery  may  be  cut  if  the  wound  is  extended  outward,  but  the 
only  muscular  fibers  which  will  be  cut  across  are  those  of  the  external 
oblique;  but  in  most  cases  the  incision  involves  only  the  aponeurosis 
of  this  muscle,  not  its  muscular  fibers. 

Locating  the  Appendix. — First  Method:  Place  two  fingers  of  the 
left  hand  inside  the  abdominal  wound  and  follow  the  parietal 
peritoneum  of  the  anterior  abdominal  wall  downward  to  Poupart's 
ligament;  then  carry  the  fingers  upward  along  the  brim  of  the  pelvis 
(recognized  by  the  pulsations  of  the  external  iliac  artery)  until  they 
are  arrested.  The  structure  which  arrests  them  will  be  the  mesentery 
of  the  ileo-cecal  region.  Usually  the  appendix  can  be  recognized  in 
this  position  by  the  sense  of  touch,  and  if  not  adherent  can  be  drawn 
out  of  the  abdominal  wound  between  the  index  and  middle  fingers. 
Second  method:  Pass  the  fingers  of  the  left  hand  along  the  parietal 
peritoneum  on  the  outer  side  of  the  wound,  and  let  them  follow  the 
parietal  peritoneum  inward  across  the  iliac  fossa.  The  structure 
which  arrests  them  will  be  the  cecum  or  ascending  colon  with  its 
mesentery.  Draw  the  cecum  into  the  wound  and  trace  its  longitu- 
dinal bands  downward  until  they  converge  at  the  base  of  the  appendix 
which  is  then  delivered.  Third  method:  This  is  less  brilliant  than 
those  just  mentioned,  but  it  is  the  surest  method  of  all.  Pack  all  the 
abdominal  contents  to  the  patient's  left,  by  inserting  gauze  sponges. 
When  all  the  movable  structures  have  been  thus  carried  away  from 
the  seat  of  operation,  only  the  immovable  will  remain.  This  is  the 
cecum,  attached  to  the  posterior  abdominal  wall  by  its  short  mesen- 
tery. When  the  cecum  is  thus  found,  draw  it  out  of  the  wound,  and 
trace  it  downward  until  the  appendix  is  delivered. 

Removal  of  the  Appendix. — (1)  Pass  an  aneurysm  needle,  carrying 
No.  1  chromic  catgut,  through  the  meso-appendix  close  to  the  base  of 
the  appendix  and  tie  this  ligature  around  the  free  border  of  the  meso- 
appendix  as  far  away  from -the  appendix  as  possible.  If  the  meso- 
appendix  is  very  thick  or  long,  it  is  safer  to  tie  it  in  two  or  three 
sections.  (2)  Cut  the  meso-appendix  as  close  to  the  appendix  as  pos- 
sible, thus  leaving  enough  tissue  beyond  the  ligature  to  prevent  its 
slipping  (Fig.  925).  (3)  Clamp  the  appendix  at  its  juncture  with  the 
cecum,  and  clamp  it  again  about  a  centimeter  distant.  Remove  the 
first  clamp  and  ligate  the  base  of  the  appendix  in  the  groove  crushed 


'IDS 


STRdERY   OF    THE  CASTRO  INTESTINAL   TRACT 


by   the  clamp,  using  No.  1  chromic  catgut  (Fig.  920).    (4)  Cut  the 
appendix  between  the  ligature  and  the  distal  clamp.     The  stump  of 


Fig.  924. — The  blood-supply  of  the  cecum  and  appendix. 


Fig.  925. — Appendectomy:  the  meso- 
appendix  has  been  tied  close  to  the  base 
of  the  cecum,  and  then  divided  close  to 
the  appendix. 


Fig.' 926. — Appendectomy:  the  base  of 
the  appendix  has  been  ligated  in  the 
groove  made  by  clamping  a  hemostat;  a 
second  hemostat  is  left  in  place. 


the  appendix  may  be  touched  with  phenol  and  with  alcohol,  but 
this  is  unnecessary.  (5)  Insert  a  purse-string  suture  of  linen  thread 
in  the  cecum  about  2  cm.  away  from  the  stump  of  the  appendix  (Fig. 


COMPLICATIONS  OF  APPENDICITIS 


909 


Fig.  927. — Appendectomy:  the  ap- 
pendix has  been  cut  off,  and  a  purse- 
string  suture  has  been  inserted  in  the 
cecum. 


927);  then  cut  the  ends  of  the  appendicular  ligature  short,  and  as 

the  stump  of  the  appendix  is  pushed  inward,  tie  the  purse-string  suture, 

thus  completely  burying  the  stump.     (6)  Look  at  the  meso-appendix  to 

make  sure  that  the  ligature  has  not  slipped,  and  then  cut  the  ligature 

short.     (7)   Finally,   close  the   abdominal  wound,   suturing   (a)   the 

peritoneum  and  posterior  sheath  of  the  rectus;  (6)  the  anterior  sheath 

of  the  rectus  and  the  internal  oblique 

and    transversalis    muscles;    (c)    the 

external  oblique  aponeurosis.     Each 

layer    is  sutured  with  a   continuous 

suture  of  chromic   catgut.     Tie  any 

bleeding    points    in    the    superficial 

fascia;  and  then  close  the  skin  wound 

with  a  buttonhole  suture  (Fig.  109) 

of  chromic  gut  (So.  0). 

In  uncomplicated  cases  of  appen- 
dicitis no  drainage  is  required,  and 
no  special  after-treatment  is  to 
be  pursued.  The  patient  may  have 
hot  water,  in  amounts  of  15  c.c. 
or    less,     every    fifteen     to     thirty 

minutes,  by  mouth,  after  twelve  hours.  Liquid  diet  is  begun  after 
twenty-four  hours  and  is  continued  for  three  days,  when  soft  diet 
is  allowed.  Full  diet  may  be  given  after  the  tenth  day,  when  the 
wound  is  first  dressed  and  the  skin  sutures  removed.  If  the  bowels 
do  not  move  spontaneously  by  the  third  or  fourth  day,  an  enema  should 
be  given,  and  only  when  this  proves  ineffectual  is  a  purge  required. 
I  prefer  to  keep  my  patients  in  bed  at  least  two  weeks,  but  many 
surgeons  allow  them  to  be  up  in  a  week  or  ten  days. 

If  operation  cannot  be  done,  then,  so  soon  as  a  diagnosis  is  made, 
treatment  should  be  instituted  as  already  advised  for  cases  of  diffuse 
peritonitis  (p.  862).  By  adherence  to  the  strictest  code  of  the  Ochsner 
treatment,  it  usually  will  be  possible  to  prevent  the  development  of 
widespread  peritonitis;  but  even  under  the  best  circumstances,  an 
abscess  will  form  or  some  other  complication  develop  in  about  10 
per  cent,  of  cases.  Nothing  is  so  surely  productive  of  complications  as 
the  administration  of  purgatives. 

Complications  of  Appendicitis. — From  a  clinical  point  of  view  the  most 
frequent  complications  of  appendicitis  are  abscess,  diffuse  peritonitis, 
and  gangrene  of  the  appendix.  There  is  no  greater  fallacy  than  to 
suppose,  as  is  done  by  many  physicians,  that  neither  abscess  nor 
peritonitis  can  occur  unless  there  is  a  macroscopical  perforation  of 
the  appendix.  Macroscopical  perforations  are  comparatively  rare, 
and  even  when  present  usually  are  of  secondary  importance  to 
the  abscess  or  the  diffuse  peritonitis  which  dominates  the  clinical 
picture. 

The  complicated  cases  of  appendicitis  under  my  own  care  treated 
by  operation  may  be  classified  thus: 


910 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


Primary  abscess in  36  per  cent. 

Residual  abscess 12       " 

Gangrene 17       " 

Diffuse  peritonitis      ....         34       " 


Mortality. 

8.4  per  cent. 
30.0 
11.1 
12.7 


The  general  mortality  for  the  entire  series  of  complicated  cases  of 
appendicitis  is  13  per  cent.     Not  one  of  these  patients  would   have 

died  if  operation  had  been  done 
within  twenty-four  hours  of  the 
onset  of  the  disease,  and  even 
those  patients  among  the  com- 
plicated cases  who  recovered 
would  have  been  saved  the 
discomforts  and  prolonged  con- 
valescence attending  a  drained 
wound. 

Primary  Appendicular  Ab- 
scess.—This  is  the  least  dan- 
gerous of  the  complications  of 
appendicitis.  The  reaction  of 
the  peritoneum  to  the  appen- 
dicular infection  is  adequate, 
and  the  infection  remains  local- 
ized to  the  immediate  neigh- 
borhood of  the  appendix.  The 
most  frequent  site  of  such  ab- 
scess is  in  the  right  iliac  fossa. 
Other  frequent  sites  are  the 
pelvis  and  the  right  flank  or 
loin,  depending  upon  the  posi- 
tion of  the  appendix  (Fig.  928).  An  abscess  on  the  median  side  of 
the  cecum,  or  among  the  coils  of  small   intestines  is  unusual;  one 


Fig.  928. — Usual  sites  of  appendicular 
abscess:  1,  in  the  right  iliac  fossa;  2,  in 
the  pelvis;  3,  in  the  right  kidney  pouch. 


Fig.  929. — Perforated  appendix,  forming  part  of  an  abscess  wall;  perforation 
into  adhesions.     Episcopal  Hospital. 

between  the  layers  of  the  mesentery  of  the  ileum,  or  elsewhere  in 
the  retroperitoneal  tissues,  is  very  rare.  In  most  cases  the  wall  of  the 
abscess  is  formed  by  the  parietal  peritoneum  of  the  iliac  fossa,  pelvis 


APPENDICULAR  ABSCESS 


911 


or  flank,  on  one  side;  by  the  cecum,  adherent  omentum  or  anterior 
abdominal  wall,  in  front;  while  its  medial  wall  is  formed  by  omentum 
or  coils  of  small  intestine.  The  appendix  usually  forms  a  part  of  the 
abscess  wall  at  some  point  (Fig.  929),  but  may  lie  entirely  within  the 
abscess  cavity.  It  may  or  may  not  present  a  macroscopical  perforation. 
Symptoms. — So  long  as  the  pus  is  under  tension  there  are  the  usual 
symptoms  of  toxic  absorption,  such  as  elevation  of  temperature, 
increase  in  the  pulse  rate,  and  leukocytosis.  If  a  differential  count 
shows  more  than  90  per  cent,  of  the  white-blood  cells  are  polynucleated, 
it  usually  indicates  the  presence  of  pus  provided  there  is  hyperleuko- 
cytosis.  A  high  white  count,  with  a  low  polynuclear  percentage, 
indicates  poor  resistance  on  the  part  of  the  patient.  If  leukocytosis 
is  not  marked  and  the  polynuclear  percentage  is  low,  it  indicates 
either  that  the  abscess  is  completely  localized  and  that  no  absorption 
is  occurring,  or  that  the  patient  is  overwhelmed  by  the  infection. 
The  clinical  picture  must  be  relied  upon  to  distinguish  between  these 
two  states.  When  only  a  small  abscess  has  formed,  and  has  become 
well  localized  so  that  no  absorption  is  occurring,  a  careless  observer 
may  be  led  to  think  that  the  patient  has  entirely  recovered.  In  such 
cases  secondary  leakage  of  the  abscess  may  occur,  resulting  in  diffuse 
peritonitis. 


Fig.  930.— Large  appendicular  abscess  two  weeks  after  onset.     X  on  anterior  superior 
spine  of  ilium.    Outlines  of  abscess  indicated  by  a  drainage  tube.    Episcopal  Hospital. 

The  physical  signs  present  depend  upon  the  duration  of  the  abscess 
and  upon  its  size.  Soon  after  the  formation  of  an  abscess,  the  rigidity 
and  tenderness  so  characteristic  of  appendicitis  in  its  earlier  stages 
may  persist  to  such  a  degree  that  recognition  of  a  mass  by  palpation 
may  be  impossible.  But  by  percussion  it  usually  is  possible  to  demon- 
strate an  area  of  dulness  in  the  right  iliac  fossa.  Such  dulness,  however, 
frequently  is  due  to  a  mass  of  adherent  omentum;  and  it  is  not  safe 
to  assume  that  a  mass,  even  if  distinct  and  papable,  contains  much 
pus.  The  quantity  of  pus  may  vary  from  a  few  drops  up  to  500  c.c. 
or  more.  Seldom  does  the  abscess  contain  more  than  10  to  15  c.c. 
of  pus.  Palpation  through  the  rectum  may  discover  a  bulging,  tender 
mass  in  the  rectovesical  pouch,  or  in  women  behind  the  uterus.  Rectal 
touch  is  particularly  valuable  in  small  children,  for  in  them  a  large 
pelvic  abscess  may  pass  unnoticed  if  this  examination  is  neglected. 


912  SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 

If  the  appendicular  abscess  lias  been  in  existence  for  several  days,  it 
usually  is  possible  to  define  its  outlines  by  palpation,  and  in  cases  of 
very  long  duration  the  abscess  may  be  visible  at  a  glance  as  a  large 
rounded  tumor  (Fig.  930). 

Residual  Appendicular  Abscess. — This  is  one  which  forms  after 
the  subsidence  of  diffuse  peritonitis  caused  by  appendicitis.  It  has 
also  been  termed  a  post-Ochsner  abscess,  because  localization  of  the 
infection  has  been  brought  about  by  adherence  to  the"  Ochsner  treat- 
ment (p.  862).  The  pathogenesis,  symptomatology,  and  treatment 
of  these  conditions  have  been  discussed  in  Chapter  XXII. 

Treatment  of  Appendicular  Abscess. — An  appendicular  abscess  should 
be  evacuated,  and  unless  the  patient  is  very  gravely  ill  the  appendix 
should  be  removed  at  the  same  operation.  But  if  it  is  very  difficult 
to  find  the  appendix,  or  if  it  is  extremely  adherent,  it  need  not  be 
removed.  Deaver  says  it  is  better  to  have  a  live  patient  with  his 
appendix  still  in,  than  a  dead  patient  without  one.  Operation  for 
abscess  should  be  undertaken  as  soon  as  possible  after  the  diagnosis 
is  made.  There  is  nothing  to  be  gained  by  delay,  and  in  many  cases, 
especially  of  residual  abscess,  there  is  danger  that  the  adhesions 
limiting  the  abscess  may  give  awTay,  and  that  diffuse  peritonitis  may 
follow  the  leakage  of  pus. 

It  is  the  teaching  of  Deaver,  and  many  surgeons  are  in  accord  with 
him,  that  it  is  best  always  to  open  the  appendicular  abscess  at  the 
place  where  it  comes  in  contact  with  the  parietal  peritoneum.  To  my 
mind  there  are  serious  objections  to  this  teaching:  (1)  in  the  vast 
majority  of  cases  there  is  no  way  of  telling  beforehand  whether  or  not 
the  abscess  is  in  direct  contact  with  the  abdominal  wall,  and  as  a 
matter  of  fact  in  a  great  many  cases  no  such  direct  contact  exists; 
(2)  in  cutting  down  upon  the  point  where  the  abscess  is  supposed  to 
be  in  contact  with  the  abdominal  wall,  one  cannot  be  sure  that  he  will 
not  extend  his  incision  too  far  in  one  direction  or  the  other  and  so 
trespass  upon  uninfected  peritoneum  at  the  same  moment  that  he 
gives  exit  to  the  pus,  thus  running  the  grave  risk  of  spreading  infection 
within  the  peritoneum;  (3)  in  an  endeavor  to  prevent  this  error  in  tech- 
nique it  is  necessary  to  make  a  funnel-shaped  wound  in  the  abdominal 
wall — very  large  in  its  superficial  part  and  very  small  in  the  depths; 
the  surgeon  has  to  work  in  a  confined  space  at  the  bottom  of  a  deep 
wound;  often  the  appendix  cannot  be  found,  and  a  second  operation 
is  necessary  to  remove  it;  and  in  any  event  the  large  wound  (made 
fortuitously  according  to  the  site  of  the  abscess,  and  not  with  respect 
to  the  anatomy  of  the  abdominal  wall)  must  be  left  open  almost  in 
its  whole  extent,  and  post-operative  hernia  is  the  rule;  (4)  last,  but  by 
no  means  least,  in  evacuating  an  abscess  in  this  way  the  surgeon  cannot 
be  sure  that  he  has  not  ruptured  the  abscess  wall  on  the  opposite  side — 
that  toward  the  general  peritoneal  cavity — thus  causing  leakage  of 
pus  into  uninfected  areas.  Only  when  the  abscess  is  almost  ready  to 
burst  through  the  abdominal  wall,  or  rarely  through  the  rectum,  and 
the  patient  is  gravely  ill,  am  I  in  the  habit  of  incising  directly  into  the 


GANGRENOUS  APPENDICITIS 


913 


abscess  cavity.  In  such  cases,  which  are  mostly  residual  abscesses, 
I  make  no  attempt  to  remove  the  appendix  at  the  first  operation, 
which  need  consume  only  about  five  minutes  and  may  be  done  under 
local  anesthesia  or  under  nitrous  oxide. 

In  the  ordinary  cases  of  appendicular  abscess  I  believe,  with  Murphy, 
that  it  is  much  safer  first  of  all  to  open  the  healthy  peritoneal  cavity 
on  the  median  or  upper  side  of  the  abscess  mass,  and  to  isolate  the 
entire  diseased  area  by  gauze 
packs.  Then  one  may  extend 
the  incision  to  as  great  a  length 
as  seems  desirable  (Fig.  931); 
and,  after  evacuating  the  ab- 
scess at  leisure  and  with  perfect 
control  of  the  infective  material, 
may  complete  the  operation  by 
removal  of  the  appendix,  and 
may  close  the  greater  part  of 
the  abdominal  wound,  leaving 
only  sufficient  space  unsutured 
for  the  emergence  of  the  drains. 
With  such  treatment  hernia  is 
a  very  rare  sequel,  and  no  sec- 
ondary operation  is  required. 

In  all  operations  for  appendic- 
ular abscess  the  surgeon  should 
make  sure  that  no  pelvic  collec- 
tion of  pus  is  overlooked.  This 
is  determined  by  passing  a  glass  tube,  along  the  fingers  as  a  guide,  to  the 
bottom  of  the  pelvis;  through  the  lumen  of  the  glass  tube  a  rubber  tube 
is  then  inserted  to  the  floor  of  the  pelvis,  and  by  means  of  a  syringe 
attached  to  its  outer  end  suction  is  exerted,  and  any  fluid  in  the  pelvis 
will  be  drawn  into  the  syringe.  If  the  abscess  occupies  the  iliac  fossa 
or  loin,  and  no  pus  is  found  in  the  pelvis  when  it  is  explored  as  just 
indicated,  it  will  be  safe  usually  to  be  content  with  drainage  extending 
only  to  the  base  of  the  appendix  and  the  site  of  the  abscess  cavity.  In 
cases  where  pus  has  been  found  in  the  pelvis,  or  in  other  cases  if  there 
is  any  uncertainty  as  to  the  efficiency  of  the  drainage,  it  is  proper  to 
drain  the  pelvis  also.  For  this  purpose  a  rubber  tube  suffices,  and  acts 
as  a  better  drain  than  does  a  wick  of  gauze.  The  drain  should  emerge 
at  the  outer  angle  of  the  transverse  incision,  or  at  the  lower  angle  of 
a  longitudinal  wound.  The  drain  should  not  be  removed  for  at  least 
four  days,  and  it  is  better  then  to  siiorten  it  by  degrees.  Too  early 
removal  of  the  drainage  frequently  leads  to  the  damming  up  of  pus 
and  the  formation  of  a  residual  abscess.  Though  such  collections 
usually  can  be  opened  by  inserting  a  finger  into  the  wound,  without  a 
general  anesthetic,  sometimes  formal  operation  is  necessary. 

Gangrenous  Appendicitis. — Though  an  appendix  associated  with 
an  abscess  or  with  diffuse  peritonitis  frequently  is  necrotic  wholly 
58 


Fig.  931. — -Very  large  transverse  incision 
in  a  case  of  appendicular  abscess,  drained 
from  its  outer  end.  Two  months  after  opera- 
tion.    Episcopal  Hospital. 


014  SURGE  in'   OF   THE  G ASTRO-INTESTINAL   TRACT 

or  in  part,  there  is  a  clinical  distinction  between  such  cases  and  those 
classed  as  gangrenous  appendicitis.  In  the  latter  class,  necrosis  of  the 
appendix  occurs  with  such  rapidity,  usually  as  the  result  of  vascular 
thrombosis,  that  no  adequate  peritoneal  reaction  develops,  and  the 
necrotic  organ  lies  free  from  limiting  adhesions  or  protecting  omentum 
in  an  almost  normal  abdomen.  Unless  such  an  appendix  is  removed 
promptly,  it  will  separate  as  a  slough  from  the  cecum  and  fecal 
extravasation  will  cause  very  severe  septic  (toxic)  peritonitis,  often 
costing  the  patient  his  life. 

There  are  no  certain  symptoms  by  which  the  occurrence  of  gangrene 
may  be  recognized;  but  sudden  cessation  of  pain,  especially  if  extreme 
tenderness  persists,  should  make  one  suspect  the  occurrence  of  gan- 
grene. The  fact  that  gangrene  has  occurred,  thus  checking  absorption 
of  toxins,  may  also  explain  rather  abrupt  disappearance  (unfortunately 
only  temporary)  of  systemic  symptoms  of  infection. 

The  only  efficient  treatment  is  immediate  removal  of  the  appendix. 
It  is  wise  to  drain  the  wound  in  every  case. 

Diffuse  Peritonitis. — The  pathogenesis,  symptomatology,  and 
indications  for  operation  have  been  discussed  at  p.  857.  In  cases 
deemed  suitable  for  operation,  the  surgeon  must  aim  to  make  the 
operation  as  short  as  possible.  After  opening  the  peritoneum,  the 
appendix  is  sought,  and  if  readily  found  is  brought  into  the  wound  and 
removed.  Then  a  glass  drainage  tube  is  passed  to  the  bottom  of  the 
pelvis,  and  any  fluid  which  has  collected  there  is  removed  by  suction 
as  described  under  the  treatment  of  pelvic  abscess  (p.  913).  If  the 
head  of  the  operating  table  is  raised  after  evacuating  the  pelvis, 
the  fluid  which  lay  in  the  patient's  flanks  will  trickle  over  the  brim  of 
the  pelvis  and  may  be  removed  thence  by  suction.  A  gauze  wick  is 
carried  down  to  the  pelvis  behind  the  glass  tube,  and  both  the  glass 
tube  and  the  gauze  wick  are  allowed  to  remain  for  drainage.  The 
patient  is  returned  to  bed  in  the  head  high  position,  and  the  usual 
treatment  for  peritonitis  (p.  862)  is  continued.  The  glass  tube  should 
be  exhausted  once  or  twice  daily,  and  at  each  dressing  should  be  rotated 
slightly  so  as  to  prevent  its  fixation  by  adhesions.  When  the  discharge 
ceases  to  be  purulent,  usually  about  the  third  or  fourth  day,  the  glass 
tube  should  be  substituted  by  one  of  rubber.  The  rubber  tube  should 
be  inserted  as  far  as  the  floor  of  the  pelvis  through  the  lumen  of  the 
glass  tube,  wThich  is  then  withdrawn  over  it ;  if  the  glass  tube  is  with- 
drawn before  the  rubber  tube  is  in  place,  the  drain  tract  will  collapse 
and  it  will  be  impossible  to  insert  the  rubber  tube.  The  gauze  wTick 
is  removed  from  the  fourth  to  the  tenth  day,  and  the  rubber  tube 
is  gradually  shortened,  allowing  the  sinus  to  heal  by  granulation. 

If  the  appendix  is  not  removed  at  the  first  operation,  the  patient 
should  be  strongly  urged  to  have  this  done  so  soon  as  convalescence 
is  complete.  The  frequency  of  second  attacks  of  appendicitis  is  great, 
and  they  are  attended  by  all  the  dangers  of  the  first.  Even  should 
no  such  acute  attacks  occur,  the  presence  of  the  diseased  organ  and  of 
the  adhesions  which  surround  it  often  seriously  impairs  the  patient's 


TUBERCULOSIS  OF  THE  APPENDIX  915 

comfort  and  may  render  him  a  semi-invalid;  moreover,  the  appendix 
may  undergo  malignant  change. 

Chronic  Appendicitis. — The  pathogenesis  of  this  condition  was  dis- 
cussed at  p.  901.  The  symptoms  are  many  and  various.  Pain  is  the 
most  constant  symptom  and  is  one  without  which  the  diagnosis  cannot 
be  made  accurately.  In  most  cases  the  pain  is  localized  to  the  region 
affected,  but  it  may  be  referred  through  the  pull  of  adhesions  to 
various  parts  of  the  abdomen.  Gastric  dyspepsia  is  frequent,  and  may 
be  the  predominant  symptom.  The  stomach,  as  W.  J.  Mayo  points 
out,  is  the  mouth-piece  of  the  gastro-intestinal  tract.  Disorders 
anywhere  in  this  tract  are  constantly  calling  attention  to  their  pres- 
ence through  disorders  of  the  stomach.  This  is  true,  of  course,  espe- 
cially of  gastric  and  duodenal  lesions;  but  it  is  equally  true  of  gall- 
stones and  of  chronic  appendicitis,  as  well  perhaps  as  of  other  less 
frequent  lesions.  The  characteristics  of  the  dyspepsia  due  to  chronic 
appendicitis  are  sufficiently  distinct  to  enable  a  diagnosis  to  be  made 
in  most  cases.  The  gastric  symptoms  occur  with  no  regularity  as 
regards  ingestion  of  food,  nor  is  relief  obtained  by  eating.  Indeed, 
eating  usually  aggravates  the  indigestion,  but  with  no  constancy  or 
regularity.  The  patient  complains  of  general  abdominal  pain,  mostly 
below  the  umbilicus.  The  patient  usually  is  about  thirty  years  of 
age.  Patients  past  thirty-five  years  much  more  often  suffer  from 
dyspepsia  due  to  gall-stones,  and  those  past  forty  years  from  that 
due  to  gastric  ulcer  or  its  sequels.  Apart  from  the  symptoms  of 
chronic  appendicitis,  a  good  deal  of  reliance  should  be  placed  on  the 
history  of  the  case,  and  particularly  on  the  physical  examination. 
Usually  there  will  have  been  one  or  two  attacks  of  abdominal  pain 
or  distress  sufficiently  acute  to  have  laid  the  patient  up  for  a  day  or 
so,  even  if  not  so  acute  as  to  have  been  recognized  at  the  time  as 
attacks  of  appendicitis.  Even  when  such  a  history  is  lacking,  deep 
palpation  of  the  abdomen  over  the  right  iliac  fossa  almost  invariably 
detects  marked  localized  tenderness  even  when  none  is  complained  of 
by  the  patient.  Chronic  appendicitis  must  also  be  differentiated  from 
ureteral  calculus  (p.  1035). 

Treatment.  ■ —  The  treatment  of  the  disease  consists  in  removal 
of  the  appendix.  Often  this  contains  a  fecal  concretion,  and  evi- 
dences may  be  found  of  past  inflammation  within  the  appendix 
(strictures,  obliteration  of  its  tip),  or  without  it  (peritoneal  adhesions, 
kinks,  etc.). 

Primary  Carcinoma  of  the  Appendix  is  found  in  less  than  1  per  cent,  of 
cases  which  come  to  operation  or  necropsy.  Without  microscopical 
examination  the  lesion  usually  is  overlooked.  It  causes  no  symptoms 
which  suffice  to  distinguish  it  from  chronic  appendicitis,  with  which 
it  often  is  associated.  Its  frequency  is  an  argument  for  the  removal 
of  the  appendix  as  an  incident  in  the  course  of  other  abdominal 
operations. 

Tuberculosis  of  the  Appendix  is  scarcely  less  frequent  than  carci- 
noma.   If  any  symptoms  are  produced  they  are  indistinguishable  from 


916  SURGERY  OF  THE  GASTRO-INTESTINAL   TRACT 

those  of  chronic  appendicitis,  except  when  the  tuberculous  infection 
has  spread  so  far  as  to  give  rise  to  the  clinical  picture  of  tuberculosis 
of  the  peritoneum  (p.  866).  The  appendix  should  be  removed  unless 
the  disease  is  so  widespread  as  to  make  this  unusually  difficult. 

Intussusception  of  the  Appendix  has  been  recorded  in  a  few  cases. 
The  symptoms  are  those  of  acute  appendicitis  and  the  treatment  is  the 
same. 

SURGERY  OF  THE  STOMACH  AND  DUODENUM. 

Gastric  and  Duodenal  Ulcer. — It  is  probable  that  these  ulcers,  as 
well  as  others  in  the  gastro-intestinal  tract,  are  toxemic  in  origin. 
In  practically  all  toxemias  there  are  gastro-intestinal  ulcers,  and  in 
practically  all  cases  of  gastro-intestinal  ulceration  there  is  present 
some  form  of  toxemia  (Dieulafoy,  Gandy,  1899).  The  toxemia  is  of 
infectious  origin,  and  the  infection  may  arise  in  a  chronically  inflamed 
appendix,  in  the  biliary  tract,  or  in  some  other  situation  which  is 
readily  overlooked.  Oral  sepsis  usually  is  present,  and  no  doubt 
has  etiological  relation;  constant  swallowing  of  pathogenic  microbes 
impairs  the  vitality  of  the  stomach,  and  its  acid  secretions  render 
it  more  vulnerable.  Mechanical  indigestion,  from  rapid  eating 
("bolting"  unmasticated  food),  is  another  important  cause. 

The  earliest  stage  in  these  gastro-intestinal  lesions  is  ecchymosis; 
then  follow  hemorrhagic  infarct,  slough,  and  hemorrhagic  erosion; 
next  is  developed  the  "exulceratio  simplex"  of  Dieulafoy;  then  comes 
the  true  ulceration  with  hemorrhagic  borders;  and  then  the  final 
stages,  perforation,  chronic  ulcer  with  thickened  border  and  little  tendency 
to  heal,  or  a  cicatrix.  These  local  effects  probably  are  due  to  the 
action  of  hemorrhagins ,  which  erode  the  endothelial  lining  of  the 
bloodvessels,  and  of  mucolysins,  which  destroy  the  gastric  mucosa. 
Ecchymosis,  the  first  stage,  is  produced  by  hemorrhagins  alone;  when 
mucolysins  also  act  an  erosion  is  produced,  and  in  time  a  fully 
developed  ulcer  will  be  formed,  unless  anti-bodies  are  formed  by  the 
organism  to  hold  these  cytolysins  in  check  (Hort,  1908).  These 
ulcers  are  not  formed  alone  in  the  stomach  and  duodenum  though 
they  are  most  frequent  here.  Other  similar  lesions,  not  so  apt  to 
produce  symptoms,  may  exist  in  the  jejunum  or  ileum  or  large  intes- 
tine, but  they  are  comparatively  rare.  In  the  mucous  membrane  of 
the  stomach  there  are  small  collections  of  lymphoid  tissue,  and  these 
are  in  greatest  number  along  the  lesser  curvature  and  in  the  pre- 
pyloric region.  It  seems  not  improbable  that  inflammation  of  these 
structures,  occurring  in  general  infections,  may  have  an  etiological 
relation  to  gastric  and  pyloric  ulcer. 

An  ulcer  in  the  stomach  or  duodenum,  when  once  formed,  is  diffi- 
cult to  heal,  partly  owing  to  trauma  from  ingested  food,  and  to  want 
of  rest  due  to  constant  peristalsis,  but  largely  owing  to  chemical 
changes  in  the  gastric  secretions,  producing  hyperacidity} 

1  Normally  it  requires  from  55  to  65  c.c.  of  decinormal  sodium  hydroxide  solu- 
tion to  neutralize  the  acidity  in  100  c.c.  of  gastric  contents.  A  figure  over  70  is 
indicative  of  hyperacidity,  and  one  under  50  of  hypoacidity. 


GASTRIC  AND  DUODENAL   ULCER  917 

Duodenal  ulcers  are  more  frequent  than  gastric  (as  3  to  2),  and  of 
gastric  ulcers  those  near  the  pylorus  and  along  the  lesser  curvature  of 
the  stomach  are  much  the  most  frequent. 

At  first  "acute,"  "round,"  or  "open"  in  type,  the  ulcer  through 
long  duration  becomes  callous,  with  thickened  borders;  and  if  healing 
finally  occurs,  in  part  or  wholly,  the  resulting  cicatrix  will  distort 
the  stomach,  and  perhaps  cause  pyloric  stenosis. 

Acute  Gastric  Ulcer  and  Duodenal  Ulcer,  are  rather  frequent  in  this 
country.  They  affect  especially  anemic  young  people,  especially 
women,  from  eighteen  to  twenty-five  years  of  age,  and  are  as  much  a 
symptom  of  their  disease  as  the  anemia  itself.  They  are  apt  to  give 
rise  to  hemorrhage  and  to  'perforation.  The  ulcers  usually  are  multiple; 
are  round;  appear  punched  out  of  the  gastric  wall;  and  usually  are 
from  0.5  to  1  cm.  in  diameter. 

Symptoms. — The  characteristic  symptoms  are  severe  burning  pain 
soon  after  eating,  relieved  by  evacuation  of  the  stomach  either  through 
the  pylorus  or  by  vomiting.  The  pain  seems  to  be  due  to  the  increased 
acidity  of  the  gastric  juice  caused  by  the  process  of  digestion,  as  well 
as  to  peristaltic  movements  and  mechanical  trauma  by  the  food. 
There  is  hyperacidity  even  of  the  empty  stomach .  Antacids  thus  relieve 
the  pain.  An  area  of  tenderness  in  the  epigastrium  is  commonly  pres- 
ent, usually  to  the  right  of  the  median  line;  sometimes  a  similar  tender 
area  is  found  just  to  the  left,  more  rarely  the  right  of  the  last  two 
dorsal  vertebra?.  Vomiting  is  frequent,  often  being  self-induced  to 
relieve  pain.  The  vomitus  often  is  streaked  with  blood,  and  quite 
independently  of  the  ingestion  of  food  hematemesis  may  occur.  Pro- 
fuse and  prostrating  hemorrhage  usually  is  due  to  an  erosion  or  an 
exulceration ;  more  moderate  bleeding,  especially  if  frequently  recur- 
rent, generally  is  due  to  the  round  open  ulcer. 

Chronic  Gastric  and  Duodenal  Ulcer;  Cicatrizing  or  Callous  Ulcer. — 
This  may  be  a  later  stage  of  the  open  ulcer  already  described,  but  it 
seems  clinically  often  to  have  been  chronic  from  its  commencement, 
whatever  its  pathological  origin.  It  is  a  much  more  frequent  disease 
in  this  country.  It  is  this  type  of  ulcer  which  is  more  often  duodenal 
than  gastric.  Mayo  has  established  the  position  of  the  pyloric  vein 
as  the  dividing  line,  and  classes  the  portion  of  the  duodenum  above 
the  bile  papilla  as  gastric  rather  than  intestinal  in  nature. 

The  ulcer,  which  usually  is  single,  has  thickened  borders,  and  is 
quite  irregular  in  outline.  Cicatrization  leads  to  contraction,  and 
pyloric  stenosis  (p.  922)  is  the  most  frequent  result.  If  the  ulcer  is 
situated  on  the  lesser  curvature,  it  often  extends  on  both  anterior  and 
posterior  walls  of  the  stomach  (saddle  ulcer) ;  and  its  cicatrization  may 
produce  hour-glass  stomach  (p.  923).  The  chronic  inflammatory 
changes  around  the  periphery  of  the  ulcer  are  thought  by  some  to  be 
forerunners  of  carcinoma  of  the  stomach  (p.  925). 

Symptoms. — These  last  a  long  time  before  relief  is  sought  from 
surgery,  so  that  the  patients  usually  are  thirty-five  to  forty  years 
of  age  or  older  when  first  seen.    The  affection  is  commoner  in  men 


918  SURGERY  OF   THE  GASTRO-INTESTINAL  TRACT 

than  in  women.  Symptoms  of  dyspepsia  overshadow  everything 
else.  These  dyspeptic  attacks,  characterized  by  flatulence,  pain, 
palpitations  of  the  heart,  epigastric  distress,  belching,  sour  eructa- 
tions, nausea  and  even  vomiting,  occur  in  periods  which  last  several 
weeks  at  a  time.  During  the  intervals  the  patient  suffers  less,  and 
is  sometimes  free  from  symptoms.  The  pain  and  distress  do  not  begin 
until  three  or  four  hours  after  meals,  and  are  relieved  by  ingestion 
of  more  food  (hunger- pain  of  Mayo  Robson).  This  is  because  the 
excess  of  acid  is  neutraliz.ed  by  food.  Patients  are  unwilling  to  go 
without  food  for  more  than  a  few  hours  at  a  time.  This  constant 
and  regular  recurrence  of  gastric  dyspepsia  several  hours  after  meals 
is  particularly  characteristic.  The  dyspepsia  due  to  chronic  appendi- 
citis (p.  915)  is  both  inconstant  and  irregular  in  its  occurrence,  and 
is  not  relieved  by  eating.  In  chronic  gastric  or  duodenal  ulcer,  how- 
ever, the  distress  from  indigestion  may  finally  become  so  extreme, 
that  a  patient  will  be  unable  to  eat  his  full  meals.  He  may  be 
reduced  to  carrying  a  bottle  of  milk  around  with  him,  taking  a  sip 
every  little  while,  to  relieve  the  burning  sensation  in  his  stomach. 
Hemorrhage,  as  has  been  remarked,  is  less  usual  in  chronic  than  in 
acute  ulcer,  and  rarely  is  large  in  amount.  If  the  ulcer  is  duodenal, 
blood  in  the  stools  (melena)  is  more  frequent  than  hematemesis;  the 
bleeding  may  be  occult  or  visible  to  the  naked  eye. 

Physical  examination  is  of  much  less  assistance  at  this  stage  of  the 
disease,  than  later,  when  pyloric  obstruction  has  developed.  Tender- 
ness is  rather  diffuse;  and  occasionally  a  mass  may  be  felt  in  the 
pyloric  region,  and  may  be  mistaken  for  carcinoma.  Roentgenologists 
place  much  confidence  in  their  ability  to  detect  even  minute  ulcers 
by  fluoroscopy  or  by  innumerable  plates  taken  in  series.  In  the  nor- 
mal stomach  the  peristaltic  waves  occur  regularly  and  are  not  inter- 
rupted in  their  course.  A  lesion  anywhere  on  the  lesser  curvature 
will  interrupt  these  waves,  because  it  produces  a  spastic  contraction 
of  the  neighboring  gastric  wall.  The  crater  of  the  ulcer  may  be 
visible  as  a  niche  in  the  gastric  wall;  and  any  distortion  of  the  normal 
outline  of  the  first  portion  of  the  duodenum  should  be  regarded  writh 
suspicion.  But  unless  the  surgeon  has  available  the  advice  of  a 
really  expert  roentgenologist,  he  will  do  well  not  to  attach  too  much 
importance  to  gastric  diagnoses  based  on  the  use  of  the  .r-rays. 

Prognosis  and  Treatment  of  Gastric  and  Duodenal  Ulcer. — Hemor- 
rhage kills  about  5  per  cent,  of  patients,  and  perforation  about  15  per 
cent.  Of  the  80  per  cent,  which  remain,  prompt,  efficient,  and  pro- 
longed medical  treatment  will  cure  perhaps  three-fourths;  but  this 
cure  seldom  is  permanent.  From  30  to  50  per  cent,  of  patients  so 
cured  have  relapses,  and  though  they  may  be  "cured"  a  number  of 
times  by  resort  to  medical  treatment,  the  cure  usually  is  attained  with 
greater  difficulty  and  is  less  lasting,  after  each  new  relapse.  Mean- 
while the  patient  is  subjected  to  the  danger  of  hemorrhage  and  per- 
foration; and  the  development  of  pyloric  stenosis,  hour-glass  stomach, 
or  carcinoma  is  the  usual  termination  in  those  patients  who  survive. 


GASTRIC  AND  DUODENAL   ULCER  919 

Medical  treatment  aims  to  encourage  healing  of  the  ulcer  largely 
by  reducing  the  acidity  of  the  gastric  juice.  This  is  accomplished  by 
regulation  of  the  diet  and  the  ingestion  of  antacids.  Surgical  treat- 
ment aims  to  effect  a  cure  either  by  excision  of  the  diseased  structures, 
or  by  altering  the  composition  of  the  gastric  juice  more  or  less  per- 
manently by  admitting  the  alkaline  duodenal  secretions  (bile  and 
pancreatic  juice)  into  the  stomach  through  a  gastro-intestinal  anasto- 
mosis. The  latter  method,  which  still  is  more  widely  employed  than 
excision,  and  which  is  more  widely  applicable,  is  attended  by  an  opera- 
tive mortality  of  3  per  cent.,  or  less,  in  the  hands  of  skilled  abdominal 
surgeons;  and  from  75  to  80  per  cent,  of  the  patients  who  recover 
are  permanently  relieved  of  symptoms  (Deaver  and  Ashhurst).  It 
is  generally  conceded,  therefore,  in  patients  whose  symptoms  recur 
after  one  or  several  "medical  cures,"  that  surgical  treatment  is  indi- 
cated; and  especially  is  this  true  of  patients  with  recurring  hemor- 
rhage.    Perforation  of  course  calls  for  immediate  operation. 

Operation. — If  the  stomach  is  not  bound  down  by  adhesions,  removal 
of  the  entire  ulcer-bearing  area  (Rodman,  1900),  as  in  cases  of  car- 
cinoma, is  preferred  by  many  surgeons;  this  is  especially  desirable 
when  there  is  much  inflammatory  thickening  around  the  base  of  the 
ulcer.  The  technique  of  this  operation  (partial  gastrectomy)  is 
detailed  at  p.  933.  Excision  of  an  isolated  ulcer  may  also  be  done. 
In  both  cases  a  complementary  gastrojejunostomy  is  done.  The 
mortality,  even  in  skilful  hands,  is  higher  than  that  of  simple  gastro- 
jejunostomy (p.  930),  and  I  believe  in  most  cases  the  latter 
operation  is  to  be  preferred,  unless  the  stomach  is  freely  movable  or 
unless  carcinoma  is  suspected.  If  there  is  no  pyloric  stenosis  Fin- 
ney's method  of  pyloroplasty  (p.  930)  will  accomplish  as  much  as 
gastrojejunostomy,  and  is  to  be  preferred  under  these  circumstances. 
It  is  well  also  to  invert  the  ulcer  by  a  few  sutures,  as  a  prophylactic 
against  subsequent  perforation. 

Perforation  of  Gastric  or  Duodenal  Ulcer. — In  most  cases,  unless  the 
patient  is  too  ill  to  talk,  he  gives  a  history  characteristic  of  the  disease. 
Perforation  may  be  acute,  subacute,  or  chronic.  An  acute  perforation 
is  one  which  occurs  into  the  free  peritoneal  cavity,  the  base  of  the 
ulcer  having  been  unprotected  by  adhesions.  A  subacute  perforation 
is  one  which  occurs  into  such  protecting  adhesions.  A  chronic  per- 
foration occurs  into  an  adherent  viscus,  such  as  pancreas,  liver,  colon, 
gall-bladder,  etc. 

Acute  perforation  is  characterized  by  very  sudden,  extremely  severe 
epigastric  pain,  often  attended  by  shock.  The  patient  doubles  up 
with  pain,  clutching  at  his  abdomen,  and  even  after  being  got  to  bed 
may  be  found  rolling  around  in  agony,  groaning  constantly  and  secur- 
ing no  relief.  Vomiting  may  or  may  not  occur.  Collapse  is  recognized 
by  the  anxiety  of  countenance,  the  cold  and  clammy  surface,  the 
sudden  pallor  and  the  guarded  breathing.  The  pulse  is  feeble  but 
may  be  either  slow  or  rapid  at  first.  The  abdomen  presents  truly  a 
"  board-like"  rigidity,  and  as  a  consequence  deep  palpation  is  valueless. 


020  SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 

If  the  patient  is  not  seen  soon  after  the  occurrence  of  perforation,  the 
effused  gastric  contents  may  have  travelled  down  the  right  flank  to 
the  cecal  region,  and  the  case  may  be  mistaken  for  appendicitis. 
After  six  or  eight  hours,  the  abdomen  becomes  distended,  secondary 
vomiting  commences,  the  pulse  quickens  and  becomes  more  feeble, 
and  other  signs  of  diffuse  peritonitis  (p.  857)  arise. 

Treatment  consists  in  immediate  laparotomy  through  the  upper 
right  rectus,  and  suture  of  the  perforation,  which  usually  is  near  the 
pylorus.  If  suture  is  impossible,  the  perforation  should  be  tamponed 
with  gauze.  If  operation  is  done  within  a  few  hours  of  perforation 
and  especially  if  suture  stenoses  the  pylorus,  or  if  the  sutures  tear  out, 
posterior  gastrojejunostomy  should  be  done  at  the  same  time.  In 
many  early  cases  the  abdominal  fluid  is  sterile,  particularly  if  per- 
foration occurred  in  a  fasting  stomach,  and  perhaps  because  of  the 
hyperacidity  of  the  gastric  juice;  but  in  all  cases  the  pelvis  should  be 
drained  (through  a  suprapubic  incision)  as  well  as  the  upper  abdominal 
wound.  Subsequent  treatment  is  the  same  as  after  any  operation 
for  diffuse  peritonitis.  If  operation  is  done  within  the  first  few  hours 
of  perforation,  the  mortality  is  only  about  15  per  cent.;  if  postponed, 
the  death  rate  rises  to  33  and  to  50  per  cent. 

Subacute  Perforation  may  be  attended  by  the  same  type  of  symp- 
toms, though  less  severe,  as  in  acute  perforation;  or  the  condition  may 
be  found  unexpectedly  at  operation  for  the  underlying  disease.  If 
a  subacute  perforation  is  suspected  in  such  a  case,  it  is  safer  to  do 
gastrojejunostomy  without  disturbing  the  adhesions  more  than  is 
necessary.  It  may  be  very  difficult  to  secure  efficient  closure  of 
such  a  perforation  by  suture. 

In  chronic  perforation  no  additional  symptoms  are  produced  at  the 
actual  moment  when  the  gastric  wall  ceases  to  form  the  floor  of  the 
ulcer  and  its  place  is  taken  by  pancreatic  tissue  or  by  firm  fibrino- 
plastic  material,  so  that  the  symptoms  which  first  call  attention  to 
the  changed  condition  are  not  those  of  perforation  nor  of  peritonitis, 
but  of  sepsis  due  to  some  form  of  perigastric  or  subphrenic  abscess, 
or  to  some  internal  fistula.  Treatment  involves  drainage  of  such  an 
abscess  and  operative  cure  of  the  gastric  lesion. 

Hemorrhage  in  Gastric  and  Duodenal  Ulcers. — The  diagnosis  usually 
is  not  difficult,  but  a  diagnosis  of  gastric  ulcer  has  been  made  in 
cases  of  bleeding  from  esophageal  varices.  Treatment  during  continu- 
ance of  bleeding  should  be  purely  medical :  morphin  hypodermically, 
an  ice  bag  to  the  epigastrium,  and  nothing  whatever  by  mouth. 
Operation  at  this  time  is  too  dangerous  to  be  recommended;  the  mor- 
tality is  from  60  to  80  per  cent.  When  the  hemorrhage  has  ceased, 
however,  and  the  patient  has  regained  some  measure  of  health,  opera- 
tion should  be  done  to  cure  the  ulcer.  Especially  important  is  this 
when  repeated  hemorrhage  occurs. 

Pyloric  Obstruction. — This  includes  three  distinct  affections: 
Infantile  Pyloric  Stenosis;  Pylorospasm;  Gastric  Dilatation. 


PYLORIC  OBSTRUCTION  921 

Infantile  Stenosis  of  the  Pylorus  (Hirschsprung,  1888)  .'—The  baby 
usually  is  healthy  at  birth,  but  within  a  week  or  so  develops  the  con- 
dition described  as  hyperemesi*  lactantium.  Unless  arrested,  the 
affection  progresses  until  gastric  peristalsis  can  be  seen  through  the 
emaciated  abdominal  wall,  and  a  pyloric  tumor  can  be  felt.  The 
obstruction  usually  is  due  to  excess  of  muscular  tissue  about  the 
pylorus.  The  cause  of  this  change  is  not  certain,  but  probably  is 
hypertrophic.  In  some  cases  medical  treatment  brings  relief  before 
complete  obstruction  develops;  but  unless  loss  of  weight  is  checked 
very  soon  operation  should  be  done. 

Rammstadt's  'pyloroplasty  (1912)  is  the  operation  usually  employed: 
an  incision  through  the  pyloric  mass  from  stomach  to  duodenum  is 
made  down  to  but  at  no  point  opening  the  mucosa;  the  thickened 
muscular  wall  is  gently  pushed  away  from  the  mucosa  by  blunt  dis- 
section, until  the  mucosa  pouts  into  the  incision,  and  the  abdomen  is 
closed.  No  sutures  are  employed  in  the  pyloric  incision.  If  injury 
to  the  mucosa  is  avoided,  the  mortality  is  very  low  (10  to  12  per  cent, 
in  the  hands  of  Downes,  Matthews  and  others)  and  uninterrupted 
recovery  is  the  rule. 

Pylorospasm. — This  is  an  intermittent  or  constant  contraction  of 
the  pyloric  sphincter,  attended  by  more  or  less  evident  symptoms. 
It  is  itself  only  a  symptom  of  a  lesion  which  may  be  in  the  stomach 
or  elsewhere.  Pylorospasm  not  infrequently  accompanies  gallstone 
colic  or  appendicitis.  In  many  cases  the  pain  is  not  very  great, 
amounting  merely  to  a  lively  sense  of  discomfort  in  the  epigastric 
region,  and  being  overshadowed  by  symptoms  of  "peristaltic  unrest 
of  the  stomach"  (Kussmaul,  1880):  when  the  pylorus  contracts 
spasmodically  the  stomach  meets  with  an  insuperable  obstacle  to  its 
evacuation;  peristaltic  unrest  ensues,  flatulence  develops  from  fer- 
mentation and  from  swallowed  air;  and,  finally,  when  the  limit  of 
endurance  is  reached,  the  pylorus  relaxes  and  gastric  contents  pass 
out  into  the  duodenum  or  the  patient  is  relieved  of  his  distress  by 
vomiting.  Secondary  gastric  dilatation  may  ensue.  Treatment  is  that 
of  the  causative  condition. 

Gastric  Dilatation. — Acute  Dilatation  of  the  Stomach  (Hilton 
Fagge,  1872)  is  met  with  as  a  complication  in  various  infectious 
diseases,  notably  typhoid  fever  and  pneumonia;  as  well  as  after  some 
operations,  not  always  involving  the  abdomen.  Though  not  caused 
by  pyloric  obstruction,  it  seems  best  to  mention  the  condition  in  this 
place. 

The  stomach  fills  nearly  the  whole  abdomen,  and  the  site  of  apparent 
obstruction  usually  is  found  at  or  near  the  duodenojejunal  angle. 
A  physiological  fact  pointed  out  by  Kelling  (1900)  may  have  some 
bearing  on  the  condition:  this  is  that  so  long  as  the  duodenum  is 
distended  the  stomach  is  unable  to  empty  itself.  Many  surgeons  still 
support  the  theory  of  Hanau-Albrecht  (1899),  that  acute  dilatation 

1  In,  1917  I  described  an  analogous  condition  occurring  at  the  ileo-cecal  valve. 


922  SURGERY  OF  THE  G ASTRO-INTESTINAL  TRACT 

of  the  stomach  is  caused  by  constriction  of  the  transverse  duodenum 
by  the  superior  mesenteric  artery,  from  the  drag  of  the  small  intestines 
(gastro-mesenteric  ileus). 

Vomiting  is  profuse  and  repeated,  and  there  is  little  nausea;  immense 
quantities  of  fluid  are  brought  up  in  this  way,  demonstrating  hyper- 
secretion by  the  stomach.  Gaseous  distention  is  extreme,  and  the 
outlines  of  the  stomach  may  be  recognized  through  the  abdominal 
wall.  When  the  stomach  tube  is  passed  there  is  an  abundant  escape 
of  odorless  gas,  with  a  gushing  or  gurgling  sound,  at  times  almost  an 
explosion.  Marked  flattening  of  the  abdomen  follows  this  evacuation, 
but  soon  the  stomach  refills  with  fluid  and  air.  Signs  of  collapse, 
largely  due  to  deprivation  of  the  tissues  of  so  much  liquid,  quickly 
follow.  Occasionally  spontaneous  relief  occurs,  and  profuse  diarrhea 
ushers  in  convalescence. 

Treatment. — Treatment  consists  in  repeated  use  of  the  stomach 
tube ;  and  in  placing  the  patient  prone  or  on  the  left  side,  with  the  foot 
of  the  bed  elevated,  with  a  view  to  overcoming  an  obstruction  at  the 
duodenojejunal  angle.  Or  the  patient  may  assume  the  knee-chest 
posture.  Operation  to  relieve  a  kink,  or  to  perform  gastrojejunostomy 
should  be  the  last  resort. 

Secondary  Gastric  Dilatation. — This  is  not  a  distinct  disease, 
but  is  the  terminal  stage  of  some  preexisting  disease  which  causes 
pyloric  obstruction.  The  most  frequent  causes  are  carcinoma,  chronic 
gastric  or  duodenal  ulcer,  or  perigastric  adhesions  usually  due  to 
disease  of  the  biliary  tract.  Benign  pyloric  obstruction  usually  is 
due  to  contraction  of  ulcers  near  the  pylorus.  Occasionally  in  the 
earlier  stages  of  ulceration  such  hyperplastic  reaction  occurs  as  to 
cause  temporary  obstruction  of  the  pylorus;  if  gastrojejunostomy 
is  done  at  this  stage  the  pylorus  may  subsequently  become  patulous, 
just  as  it  might  have  done  if  no  operation  had  been  employed.  But 
when  cicatricial  stenosis  once  develops  the  prognosis  is  hopeless  with- 
out operation. 

Symptoms. — Three  stages  are  recognized:  In  the  stage  of  compensa- 
tion it  is  only  after  an  unusually  heavy  meal  that  distress  is  experi- 
enced; gaseous  distention  becomes  oppressive,  the  clothing  is  perhaps 
unconsciously  loosened,  and  relief  eventually  is  obtained  by  the 
belching  of  gas  and  the  eructation  of  a  little  sour  fluid.  Finally  the 
wearied  stomach  empties  itself  into  the  duodenum.  This  stage  may 
last  for  months  or  years,  but  eventually  the  stage  of  stagnation  is 
developed:  here  the  stomach  is  unable  completely  to  evacuate  its 
contents  between  meals,  except  in  the  long  interval  at  night.  A  sense 
of  fulness  persists  from  one  meal  to  the  next,  and  anorexia  develops. 
Weight  may  not  be  lost,  but  none  is  gained.  In  the  stage  of  retention 
emaciation  commences  and  may  become  extreme.  The  stomach 
is  not  emptied  even  during  the  night;  lavage  before  breakfast  will 
detect  food  particles  still  in  the  stomach,  and  the  gastric  contents 
will  be  sour,  rancid,  and  usually  very  acid.  The  evidences  of  fermenta- 
tion are  pronounced,  and  production  of  gas  may  continue  after  the 


HOUR-GLASS  STOMACH  923 

stomach  contents  have  been  removed,  as  is  evidenced  by  their  separa- 
tion into  three  typical  layers  on  standing.  Because  fluids  are  not 
absorbed  from  the  stomach,  and  because  in  this  stage  they  are  late 
in  reaching  the  small  intestine,  if  they  reach  it  at  all,  there  is  more 
or  less  constant  thirst.  As  retention  becomes  extreme,  the  stomach 
occasionally  makes  an  attempt  to  empty  itself  by  the  act  of  vomiting; 
though  generally  incomplete  evacuation  is  secured,  temporary  relief 
is  obtained.  Copious  and  cumulative  vomiting  which  occurs  every 
few  days  is  very  good  evidence  that  the  stomach  is  dilated.  Occa- 
sionally tetany  occurs.     Constipation  usually  is  marked. 

Physical  Signs. — The  capacity  of  the  stomach  is  seen  to  be  increased 
not  only  from  the  large  amount  of  the  vomitus,  but  by  lavage.  Skiag- 
raphy at  various  intervals  after  the  ingestion  of  an  opaque  meal  will 
demonstrate  the  gastric  retention,  and  dilatation.  The  greater 
curvature  almost  always  is  below  the  umbilicus  and  may  reach  to  the 
pelvis.  The  stomach  may  be  cautiously  distended  with  air  by  a  hand 
bulb  attached  to  the  stomach  tube.  The  outlines  can  then  be  deter- 
mined by  percussion. 

Diagnosis. — The  diagnosis  is  based  on  a  history  indicative  of  a 
previous  disease  which  might  cause  pyloric  obstruction,  and  upon  the 
existence  of  the  symptoms  and  physical  signs  mentioned  above. 
In  gasiroptosis ,  though  the  stomach  may  be  dilated,  there  is  no  clinical 
history  characteristic  of  gastric  ulcer  or  gall-stones. 

Prognosis  and  Treatment. — This  is  the  terminal  stage  of  a  serious 
disease.  Gastric  dilatation  due  to  benign  obstruction  is  less  serious 
than  gastric  carcinoma  only  because  patients  with  the  former  disease 
die  more  slowly  than  do  those  with  cancer.  Cancer  usually  kills  in  a 
shorter  time,  but  death  in  benign  dilatation  is  quite  as  sure  even  if 
longer  delayed.  The  starvation  is  slow,  and  it  is  barely  possible  that 
the  patient  will  not  recognize  the  fact  that  he  is  starving  to  death; 
yet  he  should  be  told  that  surgery  affords  the  only  escape  from  death. 
A  measure  of  comfort  may  be  secured,  in  the  earlier  stages,  by  periodic 
gastric  lavage  and  careful  regulation  of  diet ;  but  no  true  improvement 
takes  place.  The  choice  of  operation  lies  between  gastrojejunostomy, 
which  is  preferable  in  most  cases;  partial  gastrectomy,  which  is  indi- 
cated if  malignancy  is  suspected;  and  some  form  of  pyloroplasty, 
which  is  not  to  be  recommended  except  in  patients  whose  pylorus  is 
stenosed  without  marked  thickening. 

Hour-glass  Stomach. — As  more  than  two  pouches  may  exist,  the 
term  segmented  stomach  (Wolfler,  1895)  is  preferable,  though  little 
used.  The  deformity  usually  is  the  result  of  contraction  of  an  ulcer, 
but  perigastric  adhesions  may  be  the  cause,  or  even  carcinoma  (Fig. 
932).  The  pouches  may  be  of  various  sizes,  or  diverticula  may  exist. 
The  symptoms  seldom  can  be  distinguished  from  those  of  pyloric 
obstruction,  which  often  is  present  as  an  additional  complication; 
and  the  diagnosis  depends  chiefly  on  the  use  of  fluoroscopy,  by  means 
of  which  a  constant,  persisting  constriction  can  be  recognized.  Treat- 
ment consists  in  some  form  of  operation  to  overcome  the  obstruction. 


024 


SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 


In  gastroplasty  (Fig.  933)  an  incision  is  made  through  the  constriction 
in  the  long  axis  of  the  stomach  and  is  sutured  transversely;  the  opera- 


Fig.  932. — Hour-glass  stomach  from  carcinomatous  "saddle"  ulcer  on  lesser  curvature, 
with  perforation;  death  from  peritonitis  (half  natural  size).  (Deaver  and  Ashhurst.) 
Episcopal  Hospital. 


Fig.  933. — Gastroplasty. 
Ashhurst.) 


(Deaver  and         Fig.  934. 


-Gastro-gastrostomy. 
and  Ashhurst.) 


(Deaver 


tion  is  analogous  to  pyloroplasty  (p.  930).     In  gastro-gastrostomy  (Fig. 

934)  a  lateral  anastomosis  is  made  between  the  adjacent  pouches.  Gas- 

tro-anastomosis  (Fig.  935)  is  anal- 
ogous to  Finney's  pyloroplasty 
(p.  930).  In  the  majority  of  cases 
gastrojejunostomy  in  the  cardiac 
pouch  is  to  be  preferred  to  the  oper- 
ations just  mentioned.  As  the  car- 
diac pouch  may  be  so  small  as  to 
pass  unperceived,  the  entire  stom- 
ach should  be  examined  before  any 
operation  is  done.  If  pyloric 
stenosis  also  is  present,  it  may  be 

-Gastro-anastomosis.    (Deaver  .  ,  ,  ,      .        . 

and  Ashhurst.)  necessary   to    do    pyloroplasty   in 


Fig.  935. 


CARCINOMA   OF   THE  STOMACH  925 

addition,  or  even  to  make  a  second  anastomosis,  between  the  jejunum 
and  the  pyloric  pouch. 

Plastic  Linitis  (Cirrhosis  of  the  Stomach,  Zuckergussmagen,  Magen- 
schrumpfimg,  etc.) — This  is  a  diffuse  sclerosis  of  the  stomach,  especially 
of  the  submucous  tissues,  leading  to  marked  thickening  of  the  gastric 
walls  and  diminution  in  the  capacity  of  the  stomach.  It  may  be 
benign  or  malignant  in  nature,  and  probably  may  arise  in  several 
different  diseases,  such  as  carcinoma,  syphilis,  polyserositis,  lymphatic 
obstruction,  etc.  Thomson  and  Graham  (1913)  reviewed  the  sub- 
ject at  some  length,  and  prefer  to  term  the  condition  a  "fibroma- 
tosis." If  the  change  is  recognized  early  enough,  partial  gastrectomy 
may  be  attempted;  as  a  palliative  measure  gastroenterostomy  may 
be  done,  or  even  duodenostomy  or  jejunostomy. 

Gastroptosis. — See  Visceroptosis,  p.  953. 

Carcinoma  of  the  Stomach. — This  is  a  very  frequent  disease,  but  it 
seldom  is  recognized  in  time  to  save  the  patient's  life. 

Cancer  of  the  stomach  presents  clinically  two  forms.  In  one  a 
patient  past  middle  life,  without  having  suffered  previously  from  indi- 
gestion, suddenly  loses  appetite,  especially  for  meats,  grows  pro- 
gressively weaker  and  more  emaciated,  develops  epigastric  pain  and 
possibly  a  palpable  mass,  becomes  subject  to  vomiting  spells  every 
few  days,  which  bring  up  a  quantity  of  coffee-ground  material,  foul 
smelling  and  fermented;  and  quickly  develops  the  cancerous  cachexia. 
This  is  the  classical  picture  of  gastric  carcinoma,  and  it  is  still  that 
most  frequently  seen.  It  is  less  usual  to  find  carcinoma  in  patients 
who  have  been  long  sufferers  from  dyspepsia.  The  studies  recently 
announced  by  the  pathologists  of  the  Mayo  Clinic,  tending  to  show 
that  in  75  per  cent.,  or  more,  of  cases  of  gastric  carcinoma  this  lesion 
developed  as  a  complication  of  a  preexistant  simple  ulcer,  have  not 
been  accepted  by  other  pathologists;  and  Judd  (1918)  states  that  it 
is  now  generally  accepted  that  nearly  all  gastric  cancers  have  been 
malignant  from  the  beginning. 

Pathology. — Carcinoma  of  the  stomach  occurs  oftenest  between  the 
ages  of  forty  and  seventy  years,  and  affects  the  sexes  about  equally. 
The  growth  occurs  at  the  pylorus  in  about  60  per  cent.,  and  at  the  lesser 
curvature  in  about  10  per  cent,  of  cases.  Carcinoma  of  the  body  or 
fundus  is  rare. 

Histologically  three  types  of  gastric  cancer  are  recognized:  (1) 
Spheroidal-celled  carcinoma,  composed  of  cells  like  those  normally 
lining  the  gastric  tubules;  (2)  Cylindrical-celled  or  adeno-carcinoma, 
composed  of  cells  similar  to  those  normally  lining  the  gastric  glands; 
and  (3)  Colloid  carcinoma,  a  tumor  whose  chief  characteristic  is 
myxomatous  degeneration  of  epithelial  cells  and  stroma,  which  may 
occur  either  in  the  spheroidal-celled  or  cylindrical-celled  varieties. 
Clinically  carcinoma  may  be  classed  as  scirrhous  or  medullary. 

Lymphatic  extension  occurs  early.  The  main  paths  invaded  are 
indicated  in  Fig.  936.  Our  knowledge  of  these  lymphatics  is  due 
almost  entirely  to  Cuneo  (1900),  and  to  Jamieson  and  Dobson  (1907). 


926  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

( larcinoma,  beginning  as  it  usually  docs  along  the  lesser  curvature  close 
to  the  pylorus,  invades  first  the  lymphatics  along  the  lesser  curvature, 
even  up  to  the  coronary  artery  close  to  the  cardiac  orifice  of  the 
stomach.  Hence  it  is  evident  that  every  radical  operation  for  gastric 
cancer  must  remove  the  entire  lesser  curvature  of  the  stomach.  More- 
over, so  soon  as  the  carcinoma  is  at  all  extensive,  the  lymph  nodes  in 
the  gastro-colic  omentum,  for  a  variable  distance  away  from  the 
pylorus,  are  involved.  Therefore  Hartmann's  line  for  gastrectomy 
(1901)  was  made  to  pass  from  the  coronary  artery  to  a  point  directly 
below  it  on  the  greater  curvature  (Fig.  941).  A  third  point  of  the 
greatest  importance  is  that  whereas  the  carcinomatous  invasion  extends 
rapidly  and  for  an  indefinite  distance  away  from  the  pyloric  region 
of  the  stomach,  it  invades  the  duodenum  only  rarely.    The  removal 


Fig.  936. — Paths  of  lymphatic  extension  in  carcinoma  of  the  stomach.     After 
Jamieson  and  Dobson. 

of  the  first  2.5  cm.  of  the  duodenum  nearly  invariably  enables  the 
surgeon  to  get  beyond  the  limits  of  the  growth.  Palpable  indura- 
tion stops  with  the  area  of  mucosa  involved,  but  in  the  submucosa  the 
invasion  will  have  advanced  considerably  further.  The  resection  must 
extend  from  5  to  8  cm.  away  from  the  macroscopical  tumor  on  the 
cardiac  side  of  the  growth,  and  from  1.5  to  2  cm.  from  it  on  the 
intestinal  side.  Early  lymphatic  extension,  according  to  Jamieson  and 
Dobson,  also  occurs  along  the  pyloric  and  hepatic  arteries  to  the 
suprapancreatic  lymph  nodes. 

Apart  from  the  lymph  nodes,  gastric  carcinoma  extends  oftenest  to 
the  liver,  which  is  affected  in  one-third  of  the  cases  examined  at 
autopsy.  This  invasion  occurs  along  the  radicles  of  the  portal  vein. 
In  scirrhous  carcinoma,  and  in  all  forms  which  cause  marked  pyloric 
stenosis,  invasion  of  the  liver  is  long  delayed.  Invasion  of  the  great 
omentum  may  be  followed  by  grafting  of  cancer  cells  on  the  pelvic 


CARCINOMA   OF   THE  STOMACH  927 

organs.  Invasion  of  the  left  supraclavicular  lymph  nodes,  by  permea- 
tion along  the  thoracic  duct,  is  a  very  late  sign. 

Symptoms. — Early  diagnosis  from  symptoms  alone  is  so  difficult  as 
to  be  usually  impossible.  Almost  always,  by  the  time  classical 
symptoms  have  developed,  the  disease  has  passed  beyond  the  stage 
curable  by  excision,  which  is  the  only  means  of  cure  at  present  known. 

Pain,  vomiting,  and  tumor;  loss  of  weight,  anemia,  and  changes  in 
the  gastric  secretion  are  the  classical  symptoms.  But  their  develop- 
ment is  so  late  that  they  do  not  bring  the  patient  to  the  surgeon  in 
a  curable  stage. 

Carcinoma  should  be  suspected  when  chronic  gastric  catarrh  exists 
without  any  discoverable  cause  (such  as  abuse  of  food,  of  alcohol, 
or  of  drugs;  circulatory  disturbances  of  the  heart  or  liver;  or  diseases 
such  as  cholelithiasis,  gastric  ulcer,  etc.,  which  cause  definite  lesions 
in  the  region  of  the  stomach) ;  especially  if  the  chronic  gastritis  is  in  a 
patient  over  forty  years  of  age,  and  if  it  is  attended  by  loss  of  appetite 
for  meats.  If  a  tumor  exists,  the  diagnosis  is  less  difficult;  but  the  tumor 
must  be  distinguished  from  a  distended  gall-bladder,  from  a  growth 
of  the  colon,  pancreas,  etc.  In  obscure  cases  distention  of  the  stomach 
with  air  should  not  be  neglected;  this  may  render  a  hidden  tumor  pal- 
pable, and  the  characteristic  shape  of  a  pyloric  growth  (apex  toward 
the  duodenum  and  indistinct  base  toward  the  body  of  the  stomach) 
frequently  can  be  recognized  (Kocher).  Occult  blood  in  the  stomach 
contents  and  feces  is  the  most  valuable  of  the  laboratory  findings. 
In  non-malignant  ulcerations  of  the  stomach,  rest  in  bed  with  milk 
diet  will  cause  the  disappearance  of  occult  blood.  In  cancer  no  treat- 
ment has  any  effect  (Deaver  and  Ashhurst).  Especially  characteristic 
of  carcinoma,  roentgenologically,  is  a  "filling  defect"  in  the  outline 
of  the  stomach,  but  this  also,  when  marked,  is  only  a  late  sign.  Yet 
W.  J.  Mayo  writes  (1918)  "cancers  of  the  stomach  may  be  demon- 
strated in  95  per  cent,  of  cases  in  this  way  by  the  time  they  give 
sufficient  evidence  of  their  presence  to  call  the  patient's  attention  to 
the  fact  that  something  is  wrong."  Inoperability  may  be  as  readily 
detected  by  the  .r-ray  as  by  an  exploratory  operation  (Beckman,  1915). 

Diagnosis. — The  diagnosis  can  be  only  surmised  in  most  cases  still 
in  the  operable  stage;  only  when  the  abdomen  has  been  opened  (and 
not  always  then)  can  the  surgeon  be  sure  carcinoma  is  present.  If 
a  distinct  tumor  is  present,  it  generally  can  be  recognized  as  carcino- 
matous by  its  irregular  shape,  its  "knotty"  feel,  and  by  diffused  indura- 
tion into  surrounding  structures. 

Treatment. — ^Yhenever  there  is  evidence  of  an  anatomical  lesion 
in  the  stomach  which  is  not  relieved  by  a  few  weeks  of  judicious 
medical  treatment,  exploratory  operation  should  be  undertaken  even 
though  an  exact  pathological  diagnosis  of  the  lesion  has  not  been 
reached.  Partial  gastrectomy  (p.  933)  should  be  done  even  on  sus- 
picion of  malignancy.  The  immediate  mortality  of  this  operation  is 
about  25  per  cent,  in  the  hands  of  the  average  surgeon;  even  in  the 
hands  of  Robson,  Mayo,  Deaver,  and  other  skilled  abdominal  surgeons 


928  SURGERY  OF  THE  G ASTRO-INTESTINAL   TRACT 

the  mortality  is  from  5  to  10  per  cent.  The  remote  results  indicate 
that  from  10  to  20  per  cent,  of  patients  with  carcinoma  of  the  stomach 
who  survive  radical  operation  are  cured  of  the  disease,  passing  the  three 
and  five  year  limits  without  recurrence.  This  is  a  creditable  showing 
considering  that  no  other  form  of  treatment  offers  even  the  shadow  of 
a  chance  for  cure.  Moreover,  even  if  the  patient  ultimately  dies  from 
recurrence  or  internal  metastasis,  his  life  is  prolonged  on  the  average 
for  eighteen  months  and  most  of  this  time  is  passed  in  comparative 
comfort,  and  death  finally  comes  in  less  hideous  form:  the  patient 
dies  not  of  starvation  but  of  cancerous  cachexia.  Even  when  removal 
of  the  entire  disease  by  operation  seems  impossible,  many  abdominal 
surgeons  think  that  life  is  prolonged  and  comfort  promoted  by  removal 
of  the  foul  sloughing  mass,  discharging  into  the  stomach.  It  is  well 
recognized  that  gastroenterostomy  is  not  a  good  operation  for  such 
cases;  the  immediate  mortality  is  very  high  (15  to  25  per  cent.),  and 
if  the  immediately  fatal  cases  are  included,  the  reckoning  shows 
survival  is  shorter  than  if  no  operation  had  been  employed,  while  the 
patients  who  survive  suffer  more  than  before  the  operation  and  may 
live  a  longer  time  than  if  the  abdomen  had  been  closed  without  doing 
gastro-enterostomy.  Only  in  cases  of  pyloric  obstruction  does  gastro- 
jejunostomy bring  relief.  Other  palliative  operations  have  been 
employed:  in  carcinoma  of  the  cardiac  orifice  gastrostomy  has  been 
done,  but  I  believe  it  is  contra-indicated  so  long  as  the  patient  can 
swallow  fluids.  Jejunostomy  and  even  duodenostomy  (above  the  bile 
papilla)  may  be  employed  as  euthanasial  measures  in  cases  where  the 
body  of  the  stomach  is  widely  infiltrated  and  the  patient  is  starving. 
In  employing  such  operations  the  precarious  state  of  the  patient  must 
be  remembered;  the  surgeon  should  know  before  beginning  the  opera- 
tion just  what  he  intends  to  do,  and  then  should  do  it  without  any 
unnecessary  intra-abdominal  exploration. 

Carcinoma  of  the  Duodenum,  primary,  and  not  arising  in  the  bile 
papilla  (for  which  see  p.  997)  is  very  rare.  It  has  been  carefully 
studied  by  Forgue  and  Chauvin  (1915). 

OPERATIONS  ON  THE  STOMACH. 

Gastrotomy. — The  operation  of  opening  the  stomach  may  be 
required  for  the  removal  of  foreign  bodies  within  the  stomach  or 
impacted  in  the  lower  end  of  the  esophagus;  or  for  purposes  of  explora- 
tion. The  abdominal  incision  is  made  through  the  upper  left  rectus 
muscle,  close  to  the  median  line.  The  stomach  is  located  by  finding 
first  the  left  lobe  of  the  liver  and  tracing  the  gastro-hepatic  omentum 
down  to  the  lesser  curvature  of  the  stomach.  If  a  foreign  body  is  to 
be  removed,  it  should  be  located  if  possible  before  opening  the  stomach. 
After  isolating  the  stomach  with  gauze  packs,  hold  the  foreign  body 
against  the  anterior  wall  of  the  stomach  and  cut  directly  down  upon  it, 
making  the  incision  just  long  enough  to  remove  the  foreign  body. 
Then  repair  the  gastric  incision  with  at  least  two  rows  of  sutures 
(p.  880),  and  close  the  abdominal  incision  without  drainage. 


OPERATIONS  ON  THE  STOMACH 


929 


Gastrostomy. — The  establishment  of  a  gastric  fistula,  for  the  purpose 
of  introducing  food,  is  required  most  often  in  cases  of  impermeable 
stricture  of  the  esophagus  (p.  743).  The  fistula  should  be  made  in  the 
pyloric  antrum,  and  not  in  the  fundus  of  the  stomach.  Several 
methods  of  operating  are  in  common  use. 

1.  Stamm's  Method  (1894). — The  anterior  gastric  wall  is  drawn 
into  the  wound,  and  a  small  incision  is  made,  just  large  enough 
to  admit  the  end  of  a  good-sized  catheter  (No.  26  French).  The 
catheter  (its  outer  end  clamped)  is  inserted  for  about  2  or  3  cm. 
inside  the  cavity  of  the  stomach,  and  is  fixed  to  the  gastric  wall 
by  a  single  catgut  suture.   Then 

a  purse-string  suture  of  linen  is 
taken  in  the  stomach  wall,  cir- 
cularly around  the  catheter  and 
about  1  cm.  distant  from  it;  as 
this  suture  is  tightened  the  cath- 
eter is  pushed  toward  the  cavity 
of  the  stomach  and  carries  with 
it  the  gastric  wall,  which  is  thus 
inverted  so  that  the  catheter  lies 
in  a  serous  channel  (Fig.  937). 
Two  other  purse-string  sutures 
are  similarly  passed,  and  as  each 
is  tightened  the  inverted  cone 
of  gastric  wall  is  lengthened,  so 
that  finally  the  catheter  lies  in  a 
channel    over  3    cm.  in   length. 

The  stomach  is  then  sutured  to  the  parietal  peritoneum  on  both  sides 
of  the  abdominal  wound,  and  this  is  closed  around  the  catheter. 

2.  In  WitzeVs  method  (1891)  the  tube  is  buried  in  an  oblique  manner 
in  the  gastric  wall,  by  means  of  Lembert  sutures.  After  these  sutures 
are  all  tied,  an  opening  is  made  in  the  gastric  wall  just  large  enough 
to  admit  the  end  of  the  tube;  and  after  this  has  been  introduced  and 
fixed  to  the  wall  of  the  stomach  with  one  catgut  stitch,  its  point  of 
entrance  is  covered  by  a  few  additional  Lembert  sutures  of  linen. 

The  channel  formed  from  the  cavity  of  the  stomach  to  the  skin  in 
these  operations  is  absolutely  continent  so  long  as  the  catheter  is 
in  place;  when  it  is  removed  leakage  may  occur,  but  if  the  catheter 
is  left  out  for  a  long  time  the  channel  tends  to  close  spontaneously, 
owing  to  the  adhesion  of  its  serous  surfaces.  Liquids  may  be  intro- 
duced into  the  stomach  through  the  tube  at  once  if  the  patient  is  much 
emaciated.  During  the  intervals  between  feedings  the  tube  should  be 
clamped,  and  it  should  be  withdrawn  for  cleaning  and  the  stomach 
should  be  irrigated  at  least  once  daily  after  the  first  few  days. 

Jejunostomy  (p.  928)  sometimes  is  employed  as  a  substitute  for 
gastrostomy.     Karewski  (1896)  adopted  the  technique  employed  by 
Witzel  for  gastrostomv,  while  Maydl  (1898)  emploved  a  Y-anastomosis 
(p.  932). 
59 


Fig.  937. — Gastrostomy  by  Stamm's 
method. 


930  SURGERY    OF    THE   CASTRO-INTESTINAL   TRACT 

Pyloroplasty. — The  operation  for  pyloric  stenosis  devised  inde- 
pendently by  Heinecke  and  Mikulicz  is  seldom  employed  at  present. 
It  consists  in  incising  the  pylorus  in  its  long  axis  and  then  suturing 
this  incision  transversely.  The  incision  should  extend  from  the 
stomach  clear  through  the  pylorus  into  the  duodenum.  The  opera- 
tion is  inefficient  in  preventing  recurrence  of  stenosis,  and  is  undesir- 
able because  it  is  necessary  to  work  in  diseased  tissues.  The  latter 
objection  applies  also  to  Finney's  pyloroplasty  (1902)  which  is  more 
efficient,  however,  because  it  approaches  the  type  of  a  lateral  anasto- 
mosis between  stomach  and  duodenum  (Fig.  938). 


Fig.  938. — Finney's  method  of  pyloroplasty. 

Gastrojejunostomy. — An  anastomosis  between  the  stomach  and 
small  intestine  was  first  made  in  1S81  by  Wolfler  at  the  suggestion  of 
his  assistant  Nicoladoni.  The  jejunum  was  anastomosed  with  the 
anterior  wall  of  the  stomach,  for  malignant  obstruction  of  the  pylorus. 
In  1885  von  Hacker  adopted  a  method  of  posterior  gastrojejunostomy, 
by  anastomosing  a  loop  of  the  upper  jejunum  with  the  posterior 
gastric  wall  through  an  opening  made  in  the  transverse  meso-colon. 
Most  surgeons  have  now  adopted  posterior  gastrojejunostomy  as  the 
method  of  choice,  and  use  a  jejunal  loop  as  short  as  possible,  as 
advised  in  1901  by  Petersen,  the  assistant  of  Czerny  (Fig.  939). 

The  indications  for  gastrojejunostomy  have  already  been  considered. 

The  abdominal  incision  is  made  through  the  upper  right  or  left 
rectus  muscle  close  to  the  linea  alba.  After  careful  exploration, 
the  great  omentum  and  attached  transverse  colon  are  drawn  out  of  the 
wound  and  pulled  upward  to  the  patient's  right,  thus  putting  transverse 
meso-colon  on  the  stretch,  and  bringing  the  origin  of  the  jejunum  into 
sight.  The  jejunum,  just  below  the  duodeno-jejunal  juncture,  is  brought 
forward,  and  grasped  by  the  anastomosis  forceps,  for  a  distance  of  10 
cm.  on  its  antimesenteric  border.  The  transverse  mesocolon  is  next 
cut  through  in  a  bloodless  area,  and  the  opening  is  enlarged  in  an 
antero-posterior  direction  until  it  is  from  8  to  10  cm.  in  length.  The 
posterior  gastric  wall  is  thus  exposed  and  is  made  to  protrude  through 


OPERATIONS  ON  THE  STOMACH 


931 


the  mesocolon,  whereupon  it  is  grasped  in  the  other  portion  of  the 
anastomosis  forceps.  At  least  8  cm.  of  the  gastric  wall  should  be  grasped 
in  this  way.  The  portion  grasped  should  be  in  the  pyloric  antrum,  and 
the  forceps  should  be  applied  more  or  less  transversely  to  the  long  axis 
of  the  stomach.  The  jejunal  loop  should  be  applied  to  the  stomach  in 
such  a  way  that  its  aboral  end  is  next  the  greater  curvature  of  the 
stomach,  and  its  oral  end  next  the  lesser  curvature.  Moynihan  prefers 
to  have  the  jejunum  slant  toward 
the  patient's  right;  while  Mayo 
turns  it  toward  the  left.  The  gas- 
tric wall  and  jejunum  being  thus 
apposed,  a  typical  lateral  anasto- 
mosis (p.  886)  is  made  between 
them  with  needle  and  thread.  The 
clamps  are  then  released,  and  the 
edges  of  the  opening  which  was 
made  in  the  transverse  mesocolon 
are  carefully  sutured  to  the  gastric 
wall  just  above  the  anastomosis 
by  three  or  four  interrupted  sero- 
serous  sutures.  If  this  is  ne- 
glected, a  hernia  of  the  small  in- 
testine may  occur  alongside  the 
anastomosis,  into  the  lesser  peri- 
toneal cavity.  The  abdominal 
contents  are  then  replaced  in 
proper  position,  and  the  abdom- 
inal wound  closed  without  drain- 
age. Liquids  may  be  given  in 
small  amounts  in  twelve  hours, 
but  even  semi-solid  food  should 
be  withheld  for  a  week  or  ten 
days. 

Exclusion  of  the  Pylorus. — This 
may  be  done  as  an  accessory  to 
gastrojejunostomy  in  cases  where 
the  pylorus  is  patulous.  It-  is 
probable  that  no  method  short  of 
actual  section  and  suture  of  both 
ends  will  permanently  occlude  the 

pylorus,  but  even  temporary  occlusion  is  believed  by  some  surgeons 
to  be  beneficial  in  these  cases.  A  stout  linen  thread  may  be  passed 
clear  around  the  pylorus  as  a  purse-string,  or  the  anterior  wall  may 
be  plicated  longitudinally  by  sero-serous  sutures  until  obstruction  is 
produced. 

Anterior  Gastrojejunostomy  may  be  required  when  the  posterior 
wall  of  the  stomach  proves  inaccessible  on  account  of  adhesions, 
etc.     A  loop  of  jejunum  about  35  cm.  long  must  be  used,  so  as  not 


Fig.  939. — Posterior  retrocolic  gastro- 
jejunostomy. Note  the  absence  of  a  loop 
between  the  origin  of  the  jejunum  and  the 
site  of  anastomosis  and  the  slight  distortion 
of  the  organs  when  the  operation  is  com- 
pleted. 


932 


SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 


to  constrict  the  transverse  colon.  If  the  operation  must  be  com- 
pleted with  great  speed,  a  Murphy  button  may  be  employed  for  the 
anastomosis. 

Posterior  Gastrojejunostomy  in  Y. — This,  which  was  adopted  in  1897 
by  Roux  of  Lausanne,  presents  advantages  in  some  cases:  the  jejunum 
is  divided  transversely  about  35  cm.  below  its  origin,  and  its  aboral 
segment  is  implanted  into  the  posterior  wall  of  the  stomach  through  an 
opening  in  the  transverse  meso-colon.  Then  the  oral  segment  of  the 
jejunum  is  implanted  into  the  aboral  segment  about  15  cm.  below  the 
gastro-jejunal  anastomosis  (Fig.  940).  In  this  way  there  is  no  chance 
for  the  duodenal  secretions  to  reach  the  stomach,  as  they  constantly 
do  when  the  usual  anastomosis  is  done.  The  principle  of  the 
Y-anastomosis  is  of  value  in  certain  other  intestinal  anastomoses. 


Fig.  940. — Diagram  of  posterior  gastrojejunostomy  in  Y. 


The  Vicious  Circle  after  Gastrojejunostomy  is  rarely  seen  at  present. 
When  a  long  jejunal  loop  was  used  it  was  not  infrequent.  Probably 
the  cause  is  obstruction  of  the  duodeno-jejunal  loop  at  the  point  of 
anastomosis.  The  patient  vomits  persistently  after  operation,  and 
if  repeated  lavage  proves  ineffectual  the  abdomen  may  have  to  be 
re-opened  to  relieve  the  obstruction.    The  best  treatment  is  an  entero- 


OPERATIONS  ON  THE  STOMACH 


933 


anastomosis  between  the  afferent  and  efferent  limbs  of  the  jejunal 
loop.  The  pylorus  also  should  be  occluded  by  a  purse-string  suture, 
if  still  patulous. 

A  peptic  ulcer  of  the  jejunum  occasionally  forms  at  or  below  the 
gastrojejunal  anastomosis.  It  is  seldom  recognized  except  by  hemor- 
rhage or  perforation.  Treatment  of  these  complications  is  the  same 
as  that  of  gastric  or  duodenal  ulcer.  It  may  be  necessary  to  make  a 
new  gastrojejunostomy  opening.  This  complication  is  rare  after  the 
no-loop  method  of  posterior  gastroenterostomy.  Wright  (1919) 
has  tabulated  145  proved  cases  of  this  complication:  82  patients 
recovered  and  were  relieved  of  symptoms  as  a  result  of  re-operation; 
25  were  no  better;  19  died  after  the  operation;  and  19  died  without 
operation. 


Fig.  941. — Stomach,  showing  the  Hart- 
mann  (H),  Mikulicz  (iif),  and  Mayo  (M') 
lines. 


Fig.  942. — Partial  gastrectomy  by  Bill- 
roth's  first  method. 


Gastrectomy. — A  portion  or  the  whole  of  the  stomach  may  be 
removed.  In  pylorectomy  the  pylorus  and  some  of  the  pyloric  antrum 
are  removed;  this  operation  is  employed  only  in  cases  of  benign 
disease.  In  every  case  of  malignant  disease  the  whole  of  the  lesser 
curvature  ought  to  be  removed,  and  the  operation  is  called  a  partial 
gastrectomy,  the  stomach  being  divided  at  the  Hartmann  or  Mikulicz 
line  (Fig.  941).  If  the  stomach  is  removed  as  far  as  the  Mayo  line,  the 
operation  is  known  as  subtotal  gastrectomy;  while  if  the  entire  stomach 
is  removed  from  esophagus  to  duodenum,  the  procedure  is  worthy  the 
name  of  total  gastrectomy.  Circular  or  cylindrical  gastrectomy  desig- 
nates an  operation  by  which  the  central  portion  of  the  stomach, 
including  the  entire  circumference,  is  removed. 

Partial  Gastrectomy. — Billroth' s  First  Method  (1881). — This  operation 
is  very  rarely  employed.    After  removal  of  the  diseased  area,  an  end- 


934     SURGERY  OF   THE  G ASTRO-INTESTINAL  TRACT 

to-end  anastomosis  is  made  between  the  duodenum  and  the  remaining 
portion  of  the  stomach  (Fig.  942).  As  the  circumference  of  the  latter 
is  much  greater  than  that  of  the  duodenum  leakage  is  very  apt  to 
occur  at  the  "angle"  of  the  suture  lines.  Kocher  (1891)  modified  the 
Billroth  I  technique  by  implanting  the  duodenum  into  the  posterior 
wall  of  the  stomach,  thus  avoiding  the  deadly  angle,  and  completely 
closing  the  cut  surface  of  the  stomach. 

Billroth' 8  Second  Method. — In  this  both  the  duodenum  and  stomach 
are  closed  completely,  and  the  operation  is  terminated  by  a  typical 
gastrojejunostomy.  In  Billroth's  original  technique  an  anterior  gas- 
trojejunostomy was  done;  but  whenever  possible  posterior  gastro- 
jejunostomy is  preferable. 

The  stomach  is  exposed  through  the  usual  right  rectus  incision, 
and  is  isolated  with  gauze.  The  coronary  artery  is  identified,  doubly 
ligated  and  divided,  close  to  the  cardiac  orifice  of  the  stomach.  The 
finger  is  passed  through  the  gastrohepatic  omentum  into  the  lesser 
peritoneal  cavity,  and  the  gastrohepatic  omentum  is  ligated  in  sections 
fairly  close  to  the  transverse  fissure  of  the  liver.  By  cutting  through 
the  gastro-hepatic  omentum  the  surgeon  reaches  the  pyloric  artery, 
which  is  doubly  ligated  and  cut.  The  finger  is  then  passed  down 
behind  the  pylorus,  and  the  right  gastro-epiploic  artery  is  identified 
below  the  pylorus;  this  artery  is  doubly  ligated  and  cut.  Hemostatic 
forceps  are  then  applied  to  the  gastro-colic  omentum  between  the  gastro- 
epiploic arteries  and  the  colon,  and  as  they  are  applied  the  gastro-colic 
omentum  is  divided  between  them,  beginning  at  the  pylorus  and 
passing  along  the  upper  border  of  the  transverse  colon  until  the 
point  is  reached  at  which  it  is  proposed  to  divide  the  stomach.  This 
point  should  be  5  cm.  to  the  left  of  the  visible  malignant  growth. 
When  this  point  has  been  reached,  the  left  gastro-epiploic  artery 
is  ligated  just  to  the  left  of  the  proposed  gastric  incision.  In  plac- 
ing the  hemostats  on  the  gastro-colic  omentum,  great  care  is  to  be 
taken  to  avoid  the  middle  colic  artery  and  its  branches.  The  portion 
of  stomach  to  be  removed  is  now  completely  freed  along  its  curva- 
tures, and  remains  attached  only  to  the  duodenum  and  the  body  of 
the  stomach.  The  lesser  peritoneal  cavity  can  now  be  protected 
thoroughly  by  sterile  gauze  compresses.  A  clamp  with  rubber- 
covered  blades  is  now  applied  to  the  duodenum  about  one  inch  beyond 
the  portion  visibly  diseased,  and  an  ordinary  clamp  is  applied  just  to 
the  pyloric  side  of  the  first  clamp.  The  duodenum  is  then  divided 
between  the  two.  The  entire  portion  of  the  stomach  to  be  excised 
can  now  be  turned  to  the  patient's  left.  The  duodenal  stump  is  closed 
first  by  a  through-and-through  chromic  catgut  suture;  a  purse-string 
suture  of  linen  is  applied  and  by  catching  the  duodenal  wall  in  two 
places  with  dissecting  forceps  the  sutured  end  of  the  duodenum 
is  inverted  and  the  purse-string  suture  is  drawn  tight  and  tied  (Fig. 
943).  The  gastro-colic  omentum  is  then  ligated,  and  the  hemostatic 
forceps  removed.  Rubber-covered  gastrectomy  clamps  are  then  applied 
across  the  stomach  from  the  greater  to  the  lesser  curvature,  at  least 


OPERATIONS  ON  THE  STOMACH 


935 


5  cm.  to  the  left  of  the  visible  malignant  growth.  (  lamps  with  a  screw 
lock  at  the  end  of  the  blades  are  safest.  About  2  cm.  to  the  right  of 
this  occluding  clamp  an  ordinary  forceps  is  applied,  and  the  stomach 
is  divided  between  the  two  with  the  thermocautery.  The  excised 
portion  being  removed,  a  through-and-through  suture  of  chromic  cat- 
gut is  inserted  through  the  margins  of  the  gastric  walls  which  protrude 
from  between  the  blades  of  the  rubber-covered  clamp.  It  is  well  to 
grasp  these  margins  at  one  or  more  points  with  forceps  to  prevent 
their  retracting.  ^Yhen  the  through-and-through  sutures  have  been 
completed,  the  clamp  is  removed,  and  a  continuous  sero-serous  suture 
is  applied  burying  the  first  row.  A  posterior  gastrojejunostomy  is 
then  done,  the  viscera  replaced,  and  the  great  omentum  is  drawn  up 
to  cover  the  space  left  by  the  removal  of  the  stomach. 


Fig.  943. — Partial  gastrectomy:  the  duodenum  has  been  divided,  and  the  clamps  are 
in  place  for  the  gastric  section.     (Deaver  and  Ashhurst.) 

Subtotal  Gastrectomy  differs  from  the  operation  just  described  only 
in  the  greater  amount  of  stomach  removed.  Sometimes  this  is  so  great 
that  only  an  anterior  gastrojejunostomy  can  be  done  to  complete 
the  operation.  Polya's  method  (1911)  of  anastomosis  (in  which  the 
open  end  of  the  stomach  is  implanted  into  the  jejunum  a  convenient 
distance  from  its  origin,  the  jejunum  being  brought  up  through  the 


930 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


mesocolon)  is  useful  in  such  cases;  Mayo  and  Balfour  (1017)  make  an 


antecolic  anastomosis  according 


Fig.  944.  —  Polya's  method  of  im- 
planting the  stomach  into  the  jejunum, 
after  gastrectomy. 


to  l'olya's  technique.  It  is  well  to 
attach  the  jejunum  to  the  stomach 
before  cutting  away  the  tumor  (Fig. 
944). 

Total  Gastrectomy  proceeds  along 
the  same  linesas  partial  gastrectomy ; 
the  duodenum  should  be  sutured  to 
the  esophagus  (end  to  end)  before 
the  stomach  is  completely  cut  away 
from  the  latter.  If  the  duodenum, 
even  after  mobilization  (p.  988)  can- 
not be  made  to  reach  the  esophagus 
without  undue  tension,  a  loop  of  the 
jejunum  should  be  employed  instead, 
being  drawn  through  the  transverse 
meso-colon.  The  Y-anastomosis  of 
Roux  is  valuable  under  such  circum- 
stances (p.  932). 


SURGERY  OF  THE  INTESTINES. 

Intestinal  Obstruction,  or  Ileus,  may  be  caused  by: 

1 .  Paralysis  of  the  muscular  tunic  of  the  bowel  {adynamic  obstruc- 
tion) from  bacterial  toxins,  as  frequently  seen  in  cases  of  peritonitis 
(p.  857),  or  from  lesions  of  the  spinal  cord  (p.  645). 

2.  Spasticity  of  the  muscular  tunic  {dynamic  obstruction)  which  is 
very  rare,  and  occurs  chiefly  in  cases  of  lead  or  tyrotoxicon  poisoning. 

3.  Occlusion  of  the  intestine  by  (a)  Changes  within  the  lumen  of  the 
bowel,  such  as  impaction  of  feces,  a  gall-stone,  or  other  foreign  body 
{obturation),  {b)  Changes  in  the  wall  of  the  bowel,  such  as  congenital 
malformations,  or  gradual  occlusion  by  a  tumor  or  contracting  cicatrix, 
(c)  Pressure  from  the  outside,  by  tumors  of  neighboring  organs. 

4.  Strangulation  of  the  intestine  by  (a)  Peritoneal  bands  or  adhe- 
sions.   (6)  Intussusception,    (c)  Volvulus,    {d)  Internal  Hernia.1 

Cases  of  intestinal  obstruction  are  conveniently  divided  into  two 
classes,  acute  and  chronic.  Though  cases  of  chronic  obstruction 
frequently  become  acute,  and  though  acute  cases  very  rarely  may 
become  chronic,  there  is  in  most  cases  no  difficulty  in  distinguishing 
one  from  the  other.  Most  of  the  acute  cases  are  due  to  strangulation 
or  to  obturation  from  the  sudden  impaction  of  foreign  bodies.  The 
chronic  cases  are  almost  solely  those  due  to  gradual  occlusion  of  the 
lumen  of  the  bowel  by  a  tumor  or  cicatrix  or  from  pressure  from  with- 
out. Dynamic  obstruction  is  scarcely  a  surgical  affection,  while  ady- 
namic obstruction  has  been  sufficiently  discussed  with  the  subject 
of  peritonitis.     Obstruction   from  congenital  malformations  usually 


1  Strangulation  of  external  hernia  has  been  considered  at  p.  813. 


INTESTINAL  OBSTRUCTION  937 

occurs  at  the  rectum  or  anus,  and  is  discussed  at  p.  956.  Affections 
of  Meckel's  diverticulum  are  discussed  at  p.  943. 

Acute  Intestinal  Obstruction. — The  gravity  of  this  condition 
depends  not  merely  upon  the  arrest  of  the  fecal  current  but  upon 
constitutional  symptoms.  The  higher  the  obstruction  occurs  in  the 
intestinal  tract  the  more  quickly  developed  and  the  more  pronounced 
are  these  constitutional  symptoms.  The  collapse  and  other  consti- 
tutional symptoms  of  acute  dilatation  of  the  stomach  have  already 
been  noted  (p.  921).  The  exact  cause  of  such  constitutional  symptoms 
has  not  been  determined,  in  spite  of  much  recent  experimental  work 
by  Draper,  Hoguet,  and  others. 

Symptoms. — The  local  symptoms  are  well  marked  and  easily  recog- 
nized: they  are  pain;  vomiting;  obstipation,  with  no  passage  of  flatus 
by  the  rectum;  disordered  peristalsis  which  is  always  audible 
when  the  ear  is  placed  on  the  belly,  and  may  be  visible  if  the 
abdominal  wall  is  thin;  and  finally  distention  of  the  abdomen. 
The  pain  is  characteristic;  it  is  sudden  in  onset,  very  severe, 
often  causes  the  patient  to  cry  out,  and  is  intermittent.  When  it 
ceases  the  patient  feels  and  may  look  perfectly  well,  but  it  returns 
unexpectedly  and  with  great  suddenness.  In  most  cases,  within  a 
day  or  so,  the  pain  becomes  constant,  and  is  more  or  less  localized 
to  the  seat  of  obstruction.  Sudden  cessation  of  a  fixed  pain  usually 
indicates  the  occurrence  of  gangrene.  The  vomiting  is  projectile 
in  type:  there  is  little  or  no  nausea,  and  the  patient,  unprepared  by 
previous  nausea,  suddenly  and  unexpectedly  spues  forth  a  quantity 
of  vomitus  all  over  everything.  At  first  the  vomiting  is  not  very 
frequent;  the  gastric  and  duodenal  contents  are  rejected  first,  later 
the  upper  intestinal  contents,  and  shortly  before  death  matter  that 
appears  fecal  may  be  vomited.  Though  repeated  enemas  may  secure 
an  evacuation  from  the  bowel  below  the  obstruction,  no  normal  move- 
ment occurs,  and  no  flatus  is  passed  by  rectum  at  any  time.  Eventu- 
ally the  abdomen  becomes  tympanitic  and  distended  and  the  peris- 
taltic movements  sometimes  may  be  observed  to  be  arrested  at  a 
fixed  spot,  where  the  obstruction  is  located.  The  bowel  above  the 
obstruction  becomes  much  dilated  and  undergoes  the  changes  already 
described  in  strangulated  hernia;  that  below  the  obstruction  is  col- 
lapsed. The  virulence  of  the  bacteria  above  the  obstruction  is  much 
increased,  and  the  altered  intestinal  wall  is  more  readily  traversed  by 
them,  and  thus  peritonitis  supervenes  even  before  gangrene  or  per- 
foration of  the  strangulated  bowel  takes  place.  Not  until  this  time  is 
the  temperature  noticeably  elevated,  and  though  at  this  time  also  the 
pulse  becomes  rapid  and  wiry,  in  the  early  stages  of  intestinal  obstruc- 
tion the  pulse  often  is  fuller  and  slower  than  normal.  In  this  advanced 
stage  the  diagnosis  is  difficult  between  peritonitis  with  secondary 
obstruction,  and  primary  obstruction  terminating  in  peritonitis.  The 
clinical  picture  is  that  of  the  late  stages  of  peritonitis  (p.  857).  In 
cases  of  acute  intestinal  obstruction,  unrelieved  by  operation,  death 
usually  occurs  within  a  week. 


938 


SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 


Diagnosis. — The  impaction  of  a  biliary  calculus  or  other  foreign  body 

may  be  suspected  from  the  history  of  the  case,  and  from  tlie  inter- 
mittent character  of  the  symptoms,  since  the  obstruction  seldom  is 
absolute  at  first,  the  gall-stone  shifting  its  position  within  the  lumen 
of  the  gut  from  time  to  time.  It  is  most  apt  to  become  impacted  in 
the  lower  ileum.  Obstruction  from  peritoneal  adhesions,  resulting  in 
kinks  of  the  intestine  or  constriction  beneath  a  band  of  organized 
lymph  is  most  frequent  in  children  or  young  adults  who  give  a  history 
of  one  or  more  attacks  of  peritonitis  or  of  an  abdominal  operation. 
The  symptoms  usually  are  very  severe  and  collapse  is  marked.  Intus- 
susception is  rare  in  those  more  than  two  years  of  age;  usually  it  results 
from  violent  peristalsis  induced  by  enteritis;  the  presence  of  intestinal 
parasites,  polypi,  or  enlarged  mesenteric  lymph  nodes  may  act  as 
predisposing  causes.  The  most  frequent  form  of  invagination  is  the 
ileo-cecal.  The  portion  of  intestine  which  is  sucked  down  into  the 
lumen  of  that  below  is  known  as  the  intussusceptum,  while  that  which 
receives  it  is  called  the  intussuscipiens  (Fig.  945).  The  apex  of  the 
intussusceptum  is  that  part  which  leads  the  way  in  the  lumen  of  the 
bowel  (in  an  ileo-cecal  intussusception  the  apex  of  the  intussusceptum 


4mmmwMmmm^ 


Fig.  945. — Diagram  of  an  intussusception:  A,  A'  the  apex  of  the  intussusceptum; 
C,  C  the  collar  of  the  intussuscipiens. 


is  formed  by  the  ileo-cecal  valve) ;  while  the  neck  is  the  portion  which 
enters  the  collar  of  the  intussuscipiens.  The  characteristic  symptom 
of  this  form  of  intestinal  obstruction  is  the  constant  desire  to  defecate, 
with  the  passage  of  blood  and  mucus  from  the  rectum.  Occasionally 
the  finger  introduced  into  the  rectum  will  feel  the  apex  of  the  intus- 
susceptum; and  in  many  cases  it  is  possible  to  recognize  a  sausage- 
shaped  tumor  in  the  right  or  left  hypochondrium,  the  right  iliac  region 
being  flattened  (Dance's  sign,  1826),  owing  to  the  migration  of  the 
invaginated  bowel  along  the  course  of  the  ascending  and  transverse 
colon.  Volvulus  is  most  frequent  in  adults,  especially  in  the  aged, 
and  is  said  to  occur  oftenest  in  the  sigmoid  flexure;  but  in  my  own 
experience  the  small  intestine  has  been  oftenest  involved.  The  obstruc- 
tion is  due  to  twisting  of  the  bowel  around  its  mesentery;  unless  an 
arc  of  three-fifths  of  a  circle  is  described  strangulation  does  not  occur. 
The  twist  usually  takes  place  in  contra-clockwise  direction,  the  oral 
limb  of  the  bowel  passing  above  and  to  the  right  of  the  aboral  limb. 
Volvulus  is  predisposed  to  by  elongation  of  the  mesentery  or  by  fixa- 
tion of  the  intestine  at  any  point  by  adhesions,  thus  permitting  active 
peristalsis  to  throw  the  oral  limb  over  the  aboral  portion  which  is 


INTESTINAL  OBSTRUCTION 


939 


fixed.  Rectal  examination  sometimes  reveals  a  distended  coil  of  bowel 
in  the  recto-vesical  pouch;  or  the  distended  loop  may  be  palpable 
through  the  abdominal  wall.  Internal  hernia  may  occur  in  any  of  the 
recesses  or  pockets  of  the  peritoneum,  especially  the  duodeno-jejunal 
fossa?  (Fig.  946) ;  less  often  in  the  pericecal  fossa?  or  the  mesosigmoid 
fossa.  Hernia  through  the  foramen  of  Winslow  is  rare,  as  is  a  hernia 
through  a  congenital  or  acquired  opening  in  the  mesentery  of  the  small 
intestine  (Fig.  947).  The  possibility  of  a  hernia  through  the  transverse 
mesocolon  after  the  operation  of  gastrojejunostomy  has  been  mentioned 
(p.  931).   The  diagnosis  of  these  internal  hernias  is  difficult;  usually  the 


| 


Fig.  946. 


-Diagram  of  a  case  of  strangulated  retroperitoneal  hernia  into  the  paraduodenal 
fossa.     Episcopal  Hospital. 


symptoms  are  gradual  in  onset,  and  many  cases  belong  to  the  category 
of  chronic  rather  than  to  that  of  acute  obstruction.  Sometimes  as 
the  hernia  increases  in  size  it  may  be  discovered  on  palpation,  or 
borborygmi  and  subjective  symptoms  may  point  to  the  region  of  the 
abdomen  involved. 

Treatment. — The  first  and  most  important  item  of  treatment  is 
to  avoid  purgatives.  Even  if  the  presence  of  obstruction  is  uncertain, 
the  administration  of  any  form  of  laxative  or  purge  is  absolutely  con- 
traindicated,  so  long  as  the  possibility  of  acute  intestinal  obstruction 
cannot  be  excluded.    It  is  perfectly  proper  to  use  enemas,  in  order  to 


940 


SURGERY  OF  THE  G ASTRO-INTESTINAL  TRACT 


secure  an  evacuation ;  but  purgatives  are  not  only  useless,  in  that  they 
never  relieve  the  obstruction,  but  they  are  intensely  harmful.  They 
arouse  peristalsis,  which  results  in  increase  of  the  strangulation,  and 
they  increase  the  amount  of  the  intestinal  contents  above  the  obstruc- 
tion. Some  surgeons  recommend  the  use  of  eserin,  in  cases  of  obstruc- 
tion seen  early;  they  argue  that  while  it  arouses  peristalsis  it  does 
not  cause  an  exudation  into  the  intestinal  canal  as  most  other  purga- 
tives do;  and  they  believe  that  it  will  do  good  in  cases  of  adynamic 
obstruction,  and  that  where  the  nature  of  the  obstruction  is  uncertain 
its  use  will  aid  the  surgeon  in  reaching  a  diagnosis,  since  if  nothing 
is  accomplished  or  the  patient  is  made  worse  it  may  be  assumed  that 
the  obstruction  is  not  adynamic  but  mechanical.  This  teaching  I 
regard  as  pernicious.    Though  I  have  seen  eserin  blow  the  wind  out 


Fig.  947. — Strangulation  of  a  loop  of  ileum  through  a  hole  in  its  mesentery.  A 
Meckel's  diverticulum,  adherent  to  the  anterior  abdominal  wall  prevented  more  intestine 
from  passing  through  the  mesentery.    Episcopal  Hospital. 

of  a  belly  with  great  activity,  I  have  failed  to  observe  that  such  an 
occurrence  hastens  recovery;  and  I  have  also  seen  intestinal  perfora- 
tion caused  by  the  violent  peristalsis  induced  by  eserin.  Pituitrin 
is  highly  commended  by  Gibson  (1916)  for  adynamic  obstruction: 
1  c.c.  is  injected  intramuscularly  every  hour  for  three  doses,  and  then 
every  two  hours  until  effective.  But  it  cannot  be  too  strongly 
impressed  upon  the  student  that  in  cases  of  adynamic  obstruction 
the  patient  is  not  ill  because  his  abdomen  is  distended,  but  his  abdomen 
is  distended  because  he  is  ill. 

If  there  is  any  doubt  as  to  the  diagnosis,  much  less  damage  will  be 
done  the  patient  by  resort  to  immediate  laparotomy  than  by  pro- 
crastination; and  when  operation  is  once  seen  to  be  indicated,  there 
should  be  no  delay.    The  patient  will  not  get  any  better  by  waiting. 


INTESTINAL  OBSTRUCTION  941 

But  it  is  always  well  to  wash  out  the  stomach  before  operation.  This 
will  prevent  vomiting  and  perhaps  aspiration  of  gastric  contents  into 
the  lungs  while  the  patient  is  under  the  anesthetic. 

Operation. — Unless  the  site  of  obstruction  is  definitely  known,  the 
incision  should  be  median,  below  the  umbilicus.  Do  not  let  the  dis- 
tended intestines  escape  from  the  abdomen.  Find  the  transverse 
colon;  it  is  recognized  by  the  attached  omentum.  If  it  is  distended, 
the  obstruction  is  lower,  probably  in  the  sigmoid  or  rectum,  rarely 
at  the  splenic  flexure;  if  it  is  collapsed,  the  obstruction  probably  is  in 
the  small  intestine.  Try  to  find  some  collapsed  small  intestine  and 
trace  it  upward  to  the  obstruction.  If  evisceration  becomes  necessary, 
the  eviscerated  intestines  should  be  covered  in  hot  wet  towels,  and 
these  should  be  kept  hot  and  wet  by  constant  irrigation  with  saline 
solution  at  a  temperature  of  about  115°  F.  If  the  bowel  above  the 
obstruction  is  very  much  distended  it  should  be  emptied  of  its  highly 
infectious  contents  by  aspiration  or  incision.  Monks  advocated  passing 
a  glass  tube  up  the  lumen  of  the  distended  intestine,  and  crowding  as 
many  coils  of  bowel  upon  it  as  possible,  to  aid  in  securing  evacua- 
tion. I  tried  this  method  on  several  occasions,  but  did  not  find  it 
effectual.  If  the  condition  of  the  patient  is  very  bad,  the  operation 
may  be  terminated  by  establishing  a  false  anus  above  the  obstruction, 
as  in  cases  of  acute  obstruction  superimposed  upon  chronic  obstruction 
(p.  942);  and  in  almost  moribund  patients  life  is  occasionally  saved 
by  opening  the  first  distended  coil  of  intestine  which  presents  itself 
without  making  any  search  whatever  for  the  obstruction;  this  consti- 
tutes the  old  operation  of  enterotomy.    It  was  revived  by  Krogius  (1911). 

If  obstruction  is  due  to  the  impaction  of  a  foreign  body,  it  should  be 
dislodged  if  possible  and  removed  through  an  incision  in  healthy 
intestine. 

If  the  obstruction  is  due  to  kinking  from  adhesions,  these  usually 
may  be  separated  with  the  fingers  or  gauze  dissection;  distinct  bands 
must  be  cut.  The  denuded  areas  on  the  intestines  should  be  inverted 
by  sero-serous  sutures,  or  should  be  covered  with  omentum.  If  the 
adhesions  are  very  widespread  and  the  bowel  very  friable,  a  short- 
circuiting  operation  (p.  949)  may  be  necessary. 

In  cases  of  intussusception,  efforts  at  reduction  should  be  made  by 
pushing  the  intussusceptum  back,  not  by  attempts  to  pull  it  out 
from  above.  The  latter  method  rarely  is  successful,  and  may  be  pro- 
ductive of  much  damage.  If  reduction  proves  impossible,  the  intus- 
suscipiens  may  be  incised  longitudinally  and  the  intussusceptum 
removed,  the  incision  being  closed  and  the  neck  and  collar  of  the  invag- 
inated  bowel  being  sutured  together.  Enterectomy  rarely  is  justi- 
fiable in  this  or  any  form  of  acute  obstruction;  the  establishment 
of  a  false  anus  above  the  obstruction  (if  this  is  not  too  high  in  the 
intestinal  tract)  or  a  short-circuiting  operation  will  be  preferable. 
Occasionally  the  gangrenous  intussusceptum  separates  as  a  slough 
and  is  discharged  by  rectum.  The  operative  mortality  is  about  33 
per  cent. 


942 


SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 


In  cases  of  volvulus,  the  bowel  should  be  untwisted,  and  if  the  condi- 
tion of  the  patient  permits,  it  is  well  to  take  a  reef  in  the  redundant 
mesentery  or  to  attach  the  sigmoid  to  the  parietal  peritoneum,  so  as  to 
prevent  recurrence. 

Chronic  Intestinal  Obstruction. — This  is  most  often  the  result  of 
fecal  impaction,  benign  or  malignant  stricture,  or  widespread  peri- 
toneal adhesions  which  interfere  with  peristalsis  without  causing 
strangulation. 

In  fecal  impaction,  which  occurs  oftenest  in  the  rectum  or  sigmoid, 
rarely  in  the  transverse  colon  or  cecum,  there  is  obstinate  constipa- 
tion, with  slight  intermittent  colicky  pains  from  disordered  peristalsis; 
sometimes  a  mass  can  be  felt  through  the  abdominal  wall,  which  is 
recognized  as  fecal  from  its  doughy  consistency.     Vomiting  (never 


Fig.  948. — Cecostomy,  for  acute  intestinal  obstruction,  of  one  week's  duration,  super- 
vening on  chronic  obstruction  of  twelve  years'  standing.  Paul's  tube  in  cecum.  Stricture 
of  sigmoid,  in  woman  of  fifty-three  years,  following  injury  in  childbirth  thirteen  years 
ago.      (See  page  966.)      Episcopal  Hospital. 

stercoraceous)  may  occur  during  an  acute  attack;  and  watery  diarrhea 
often  follows  relief  of  the  obstruction.  Treatment  comprises  the  use 
of  repeated  enemas,  administered  in  the  Trendelenburg  or  knee- 
chest  posture,  and  evacuation  of  fecal  masses  from  the  rectal  ampulla 
by  the  finger  if  necessary.  When  once  the  impaction  is  relieved,  it 
is  safe  to  give  purges;  as  long  as  any  acute  symptoms  persist  opium 
and  belladonna  may  be  of  use  in  relaxing  intestinal  spasm. 

In  chronic  obstruction  from  a  cicatrix  or  tumor  of  the  intestine, 
the  symptoms  are  much  the  same  as  in  fecal  impaction,  but  as  a  rule 
no  tumor  can  be  felt.  After  many  attacks  of  partial  obstruction,  this 
is  prone  to  become  acute  and  complete  at  the  last.  If  palliative  treat- 
ment (enemas)  proves  unavailing  the  surgeon  should  open  the  abdo- 
men, and  in  the  presence  of  acute  obstruction  should  content  himself 
with  making  a  false  anus  above  the  seat  of  the  tumor;  if  there  is  no 
evidence  of  acute  obstruction  the  tumor  or  cicatrix  may  be  resected, 
but  such  a  course  almost  always  leads  to  death  from  peritonitis  unless 


MECKEL'S  DIVERTICULUM 


943 


the  bowel  above  the  tumor  is  unobstructed.  If  the  tumor  is  in  the 
rectum,  a  sigmoid  anus  may  be  made  in  the  left  iliac  region  (Littre's 
operation,  1710);  but  if  the  tumor  is  higher  in  the  large  intestine 
cecostomy  (Fig.  948)  should  be  done  in  the  right  iliac  region  (Pillore, 
1776).  For  obstruction  in  the  small  intestine,  which  is  rare,  a 
short-circuiting  operation  is  preferable  (entero-enterostomy). 

Mesenteric  Thrombosis  and  Embolism. — Thrombosis  of  the  mesen- 
teric vessels  occurs  in  many  cases  of  intestinal  obstruction,  as  the  result 
of  strangulation.  But  thrombosis,  and  rarely  embolism,  may  occur 
as  a  primary  condition,  from  the  same  causes  which  produce  similar 
conditions  in  other  parts  of  the  body.  The  symptoms  are  not  unlike 
those  of  acute  intestinal  obstruction,  except  that  pain  occasionally  is 
inconspicuous  in  cases  of  thrombosis;  peritonitis  develops  more  rapidly 
than  in  intestinal  obstruction;  and  there  are  evidences  of  hemorrhage 
into  the  intestinal  tract,  with  bloody  diarrhea  or  vomiting.  Diagnosis 
is  difficult.  Trotter  (1913)  collected  366  cases,  in  only  13  of  which  was  a 
correct  diagnosis  made.  Treatment  comprises  immediate  laparotomy 
and  resection  of  the  affected  bowel,  which  quickly  becomes  gangrenous. 
The  mortality  is  36  per  cent,  in  cases  treated  by  resection  (Trotter). 
If  the  condition  of  the  patient  renders  resection  impossible,  the  gut 
may  be  tamponed,  or  may  be  drained;  but  incomplete  operations 
almost  always  terminate  fatally. 

Meckel's  diverticulum,  the  remains  of  the  omphalo-mesenteric 
duct,  is  found  in  about  2  per  cent,  of  bodies  which  come  to  autopsy. 
It  is  attached  to  the  lower  ileum, 
within  a  few  feet  of  the  cecum, 
and  usually  springs  from  the  anti- 
mesenteric  border  of  the  gut.  It  is 
about  the  size  of  the  finger,  and 
may  be  unadherent,  or  may  be  at- 
tached to  the  umbilicus  (see  Um- 
bilical Fistula)  or  to  some  other 
point  in  the  abdomen.  It  is  most 
apt  to  cause  trouble  if  adherent, 
acting  as  a  band  under  or  around 
which  the  intestine  becomes  stran- 
gulated. If  adherent  to  the  um- 
bilicus, volvulus  of  the  small  in- 
testine is  frequent,  causing  torsion  FlG  949  _  (trangulation  of  Meckel's  di- 
and  perhaps  Strangulation  of  the  verticulum,  adherent  to  umbilicus.  Age 
,.         ;.      ,  ,-,-,.       ?nn\        th  forty-six  years;   duration  two  days.     Epis- 

diverticulum  (Iig.  949).     11  unat-   CoPai  Hospital. 
tached,  its  chief  affection  is  acute 

inflammation,  which  in  its  pathogenesis,  symptomatology  and  treat- 
ment resembles  appendicitis. 

Diagnosis. — The  presence  of  a  Meckel's  diverticulum  may  be  sus- 
pected if  the  umbilical  cicatrix  is  abnormal.  I  have  twice  been  able 
to  make  the  correct  diagnosis  before  opening  the  abdomen,  by  heed- 
ing this  maxim. 


944     SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

Treatment. — It  is  best  to  excise  the  diverticulum,  at  the  same  time 
(loins  what  is  necessary  to  the  strangulated  intestine. 

Umbilical  Fistula. — If  the  omphalo-mesenteric  duct  remains  patu- 
lous, a  fistula  is  present  at  the  umbilicus.  This  may  discharge  feces, 
or  if  very  small  only  mucus.  In  some  cases  the  discharge  resembles 
gastric  juice  and  it  is  uncertain  whether  the  mucosa  from  which  the 
discharge  comes  is  an  excluded  part  of  Meckel's  diverticulum,  or 
neoplastic  (adenomatous)  in  nature  (Denuce,  1908).  The  best  treat- 
ment is  extirpation  of  the  diverticulum. 

Affections  of  the  Urachus  are  discussed  at  p.  1017. 

Internal  Fistulae  of  the  Intestinal  Tract  usually  are  the  result  of 
peritonitis,  malignant  disease,  or  tuberculosis.  Occasionally  they 
result  from  injury.  The  existence  of  a  fistula  between  the  gall-bladder 
and  the  intestine  may  be  inferred  if  a  large  gall-stone  is  passed  by  rec- 
tum or  lodges  in  the  intestine;  such  fistula?  often  close  spontaneously 
and  rarely  cause  symptoms.  A  gastro-colic  fistula  gives  evidence  of 
its  presence  chiefly  by  the  development  of  lienteric  diarrhea  and 
fecal  vomiting.  Other  forms  of  internal  fistula  are  rare  and  do  not 
cause  characteristic  symptoms.  Gastro-colic  fistula?  scarcely  ever 
close  spontaneously,  and  early  operation  is  indicated.  Tbe  best  plan 
is  to  separate  the  stomach  and  colon  and  repair  the  perforation  in 
each.  But  this  is  not  always  possible.  Alternate  methods  are  (1) 
section  of  the  colon  on  each  side  of  the  fistula,  and  bilateral  exclusion 
(p.  952)  of  the  portion  of  bowel  containing  the  fistula,  leaving  it  as  a 
pouch  attached  to  the  stomach,  and  reuniting  the  colon  above  and 
below  the  seat  of  disease ;  (2)  short-circuiting  the  fecal  current  by  a 
colo-colostomy  (above  and  below  the  fistula)  or  by  ileo-sigmoidostomy ; 
but  neither  of  these  plans  is  very  satisfactory. 

Intestinal  Perforation  in  Typhoid  Fever  occurs  in  about  2.5  per  cent, 
of  cases.  It  is  most  frequent  during  the  third  or  fourth  weeks  of  the 
disease  and  is  predisposed  to  by  a  mixed  infection  in  the  intestinal 
tract.  The  great  majority  of  perforations  occur  in  the  ileum,  within  a 
few  feet  of  the  cecum.  The  important  symptoms  are  abdominal  pain, 
localized  muscular  rigidity,  increase  in  the  pulse  rate,  and  often  a  fall 
in  the  temperature  immediately  after  the  perforation.  But  the  patient 
may  be  too  toxic  to  complain  of  pain,  and  the  other  symptoms  may 
pass  unnoticed  unless  the  physician  and  nurse  are  constantly  alert. 
Very  soon  rigidity  is  lost,  distention  commences,  and  often  it  is  not 
until  widespread  peritonitis  is  developed  that  the  surgeon  is  asked 
to  see  the  patient.  The  sooner  operation  is  done,  the  better  the  chance 
of  recovery.  Consent  for  immediate  operation  should  be  obtained 
before  perforation  occurs  if  its  occurrence  seems  probable.  If  a  pre- 
perforative  stage  (peritonitis  without  symptoms  of  perforation)  can 
be  recognized,  it  is  proper  to  open  the  belly  then,  and  to  prevent 
perforation  by  inverting  all  ulcers  wrhich  threaten  to  perforate  or  by 
establishing  a  fecal  fistula  above  the  level  of  diseased  bowel.  Even 
if  no  lesion  is  found  {laparotomie  blanche)  the  patient  is  none  the 
worse  for  the  exploration. 


IN  TES  TINAL   PER  FOR  A  TION 


945 


The  operation  may  be  done  under  spinal  or  local  anesthesia,  but  I 
prefer  a  general  anesthetic  (ether  or  gas).  The  incision,  about  7 
cm.  long,  is  made  through  the  right  rectus  muscle,  below  the  umbili- 
cus (Fig.  950) ;  and  the  lowest  loop  of  ileum  (located  as  described  at 
p.  878)  is  pulled  into  the  wound 
and  traced  upward  until  the  per- 
foration (there  may  be  more  than 
one)  is  found  or  until  healthy 
bowel  is  reached.  When  a  perfor- 
ation is  found  it  should  be  closed 
by  a  purse-string  or  other  appropri- 
ate suture (  p.  881)  in  such  a  way  as 
not  to  stenose  the  bowel.  If  the 
patient  is  desperately  ill,  it  is  suffi- 
cient to  drain  the  intestine  above 
the  area  of  disease  by  a  Paul's  tube 
(p.  970),  tamponing  the  necrotic 
bowel.  Drainage  to  the  pelvis 
always  should  be  employed,  but  I 
consider  irrigation  of  the  peritoneal 
cavity  harmful.  Subsequent  treat- 
ment is  the  same  as  for  peritonitis. 

In  collective  statistics  (Harte 
and  Ashhurst,  1904)  the  mortality 
is  nearly  75  per  cent.;  but  a  few 
individual  operators  report  a  death- 
rate  well  below  60  per  cent.  (Montreal  General  Hospital,  Johns  Hop- 
kins Hospital).  In  my  own  hands  the  mortality  has  been  61.5  per 
cent.;  this  includes  one  patient  who  recovered  after  cholecystectomy 
for  perforation  of  the  gall-bladder  during  typhoid  fever  (Fig.  951),  and  a 
case  of  recovery  after  removal  of  an  acutely  inflamed  appendix  during 
typhoid  fever  and  a  recovery  after  a  laparotomie  blanche. 


Fig.  950.  —  Scar  four  months  after 
operation  for  intestinal  perforation  in 
typhoid  fever.     Episcopal  Hospital. 


Fig.  951. — Gall-bladder  removed  by  cholecystectomy,  showing  typhoid  perforation. 
(Natural  size.)     Episcopal  Hospital. 


Intestinal  Hemorrhage  in  Typhoid  Fever  is  of  surgical  interest, 
chiefly  in  connection  with  the  diagnosis  of  perforation.  In  hemor- 
rhage, though  there  may  be  marked  shock,  increase  of  pulse  rate  and 
fall  of  temperature,  there  seldom  is  pain  or  marked  abdominal  rigidity; 

60 


946 


SURGERY  OF   THE  CASTRO-INTESTINAL   TRACT 


and  usually  the  blood  appears  in  the  stools  within  an  hour  or  so. 
In  severe  recurring  hemorrhages,  which  usually  are  fatal,  Ilarte  (1909) 
advocates  laparotomy;  he  succeeded  in  finding  the  bleeding  spot  by 
the  aid  of  transmitted  light,  and  in  checking  the  bleeding  by  suture. 
Though  his  patients  eventually  succumbed,  he  has  indicated  the 
proper  course  to  pursue  in  such  cases. 


Fig.  952. — Diagram  of  a  fecal  fistula. 

Fecal  Fistula  and  False  Anus. — If  only  a  small  portion  of  the 
intestinal  contents  (perhaps  only  flatus)  is  passed  from  the  bowel 
through  the  opening  in  the  abdominal  wall,  the  patient  is  said  to  have 
a  fecal  fistula  (Fig.  952);  but  if  practically  the  entire  intestinal  con- 
tents are  discharged  in  this  way,  a  false  anus  (Fig.  953)  is  said  to 
exist. 


Fig.  953. — Diagram  of  a  false  anus,  with  formation  of  a  marked  spur. 

A  fecal  fistula  sometimes  develops  in  a  drained  abdominal  wound 
a  few  days  after  operation  in  cases  where  the  bowel  was  gangrenous, 
but  the  fecal  discharge  usually  ceases  spontaneously  after  removal 
of  the  drainage,  as  the  wound  granulates.  Its  closure  is  aided  by  con- 
fining the  patient  to  as  dry  a  diet  as  possible,  and  by  securing  an 
evacuation  through  the  rectum  every  day  by  means  of  an  enema. 
Purges  are  contraindicated.  To  prevent  excoriation  of  the  skin  around 
the  fistula,  it  may  be  covered  with  zinc  oxide  ointment.  Mineral 
bases  should  be  used  in  all  such  ointments,  as  animal  bases  sometimes 
are  digested  by  the  intestinal  juices. 


FECAL  FISTULA 


947 


A  false  anus  usually  is  an  artefact,  intentionally  produced  by  the 
surgeon  (Fig.  974) ;  though  it  may  also  develop  spontaneously,  by  the 
gradual  formation  of  a  spur  in  a  case  of  fecal  fistula.  It  shows  no  ten- 
dency to  heal,  owing  to  the  presence  of  this  firm  spur  between  the  affer- 
ent and  efferent  loops  of  bowel ;  operation  almost  always  is  necessary  to 
secure  its  closure.  In  some  cases,  where  it  is  certain  that  the  afferent 
and  efferent  loops  of  bowels  are  in  close  apposition,  it  is  safe  to  destroy 
the  spur  by  passing  one  blade  of  a  clamp  into  each  opening  and  gradu- 


K 

.vt: 

f 

J-., 

i 

\ 

Fig.  954. — Carcinoma  of  the  ascending  colon.  (See  also  Figs.  955  and  956.)  Stricture 
admitted  goose-quill  (0.5  cm.  in  diameter).  Specimen  excised  included  the  ileocecal 
coil  and  entire  ascending  colon.  Specimen  has  been  slit  down  the  anterior  wall  through 
the  stricture.     Patient   died  in  two  days.     Episcopal   Hospital. 


ally  tightening  the  clamp  throughout  a  period  of  several  days  until 
pressure  has  caused  a  slough  to  form,  and  converted  the  lumen  of  the 
two  intestines  into  one.  Dupuytren's  enterotome  is  the  type  of 
instrument  employed.  If  this  can  be  satisfactorily  accomplished  the 
external  opening  of  the  fistula  usually  closes  spontaneoulsy.  In  most 
cases,  however,  a  radical  operation  must  be  done.  This  consists  in  dis- 
secting widely  around  the  false  anus,  opening  the  healthy  peritoneal 
cavity,  which  is  well  protected  by  gauze  packs,  and  closing  the  open- 
ing in  the  bowel  by  inversion  of  its  margins  where  this  is  possible; 


•IIS 


sriWKRY  <>!■'   THE  G ASTRO-INTESTINAL  TRACT 


and  in  other  cases  by  resection  of  the  affected  bowel,  and  restoration 
of  the  continuity  of  the  intestinal  tract  by  end-to-end  or  lateral  anas- 
tomosis. 


Fig.  955. — -Carcinoma  of  the  ascending  colon.     Barium  fills  the  small  intestines  but  has 
not  passed  obstruction.    Some  is  still  in  the  stomach.    (See  Fig.  954) .    Episcopal  Hospital. 


Fig.  956. — Excision  of  the  ascending  colon  with  implantation  of  terminal  ileum  into 
transverse  colon.      (See  Figs.  954  and  955). 


Tumors  of  the  Intestine,  except  of  the  sigmoid  and  rectum  (for 
which  see  page  968),  are  quite  rare.  Benign  tumors  are  almost  unknown 


OMENTAL  CYSTS 


949 


with  the  exception  of  mesenteric  cysts  (see  below).  Hyperplastic 
tuberculosis  and  malignant  tumors  (sarcoma  and  carcinoma)  produce 
symptoms  by  obstructing  the  bowel.  Sometimes  melena  or  enter- 
orrhagia  occurs.  If  the  tumor  is  recognized  as  soon  as  symptoms  of 
chronic  obstruction  appear,  it  is  usually  possible  to  remove  it  by  intes- 
tinal resection  with  fair  prospect  of  ultimate  recovery.  Lymphatic 
extension  generally  occurs  late.  In  malignant  tumors  of  the  small 
intestine  resection  with  end-to-end  or  lateral  anastomosis  may  be  done. 
In  carcinoma  of  the  cecum  (which  sometimes  gives  a  palpable  tumor 
before  obstructive  symptoms  arise)  or  of  the  ascending  colon  it  is 
best  to  resect  the  entire  ileocecal  coil  of  intestine  as  high  as  the  dis- 
tribution of  the  middle  colic  artery  (Figs.  954,  955,  956).  The  con- 
tinuity of  the  intestinal  tract  is  restored  by  implanting  the  ileum  into 
the  transverse  colon  or  the  sigmoid.  If  resection  is  impossible  in  any 
case  (and  it  never  should  be  attempted  when  acute  obstruction  has 
developed)  a  false  anus  may  be  established  above  the  site  of  obstruc- 
tion; or  a  short-circuiting  operation  (Fig.  957)  or  an  intestinal  exclusion 
(Fig.  958)  may  be  performed.  The  tumor  is  to  be  resected  when 
convalescence  is  well  established. 


Fig.  957. — Ileo-sigmoidostomy,  a  typical 
"short-circuiting"  operation. 


Fig.  958. — Unilateral  exclusion  of  the 
ascending  colon,  by  implantation  of  the 
ileum  into  the  transverse  colon. 


Mesenteric  Cysts  usually  are  of  embryonal  origin,  and  are  endo- 
theliomatous  in  nature.  Hydatid  cysts,  and  cystic  degenerations  of 
malignant  tumors,  also  occur.  Adhesions  are  common,  but  the 
tumor  usually  is  movable  laterally;  it  is  surrounded  by  a  tympanitic 
area,  and  may  be  crossed  by  a  band  of  tympany.  Its  most  frequent 
site  is  in  the  mesentery  of  the  lower  ileum.  H.  C.  Deaver  collected 
40  cases  in  1909.  The  proper  treatment  is  extirpation,  which  often 
involves  resection  of  the  overlying  intestine. 

Omental  Cysts  of  the  same  nature  occasionally  occur. 


950  SURGERY  OF   THE  CASTRO-INTESTINAL   TRACT 

SURGERY  OF  THE  COLON  AND  SIGMOID. 

Colitis. — Three  types  of  this  disease  may  be  recognized:  (1)  Ordi- 
nary "catarrhal"  colitis  or  entero-colitis,  without  known  specific 
cause,  due  originally  to  errors  in  diet,  exposure,  etc.  (2)  Bacillary 
dysentery,  due  to  the  B.  dysenterise  of  Shiga,  which  usually  is  an  acute 
disease  and  often  rapidly  fatal,  and  which  is  the  common  epidemic 
form  of  dysentery  which  devastates  camps,  prisons,  etc.  (3)  Amebic 
dysentery  caused  by  the  amoeba  dysenterise  (A.  coli),  which  even 
if  acute  or  subacute  at  first  almost  always  terminates  as  a  chronic 
disease.  It  is  almost  solely  with  the  latter  group  of  cases  that  surgery 
is  concerned,  since  except  in  the  rare  event  of  perforation  or  abscess 
formation  the  first  and  second  are  best  treated  medically. 

In  amebic  dysentery  the  entire  colon  or  only  parts  of  it  may  be 
affected.  As  the  sloughs  are  cast  off  ulcers  are  left,  and  these  may 
cicatrize  or  perforate,  while  new  ulcers  are  forming  in  other  parts  of 
the  colon.  The  sloughs  may  be  passed  by  rectum  in  large  masses 
(membranous  dysentery).  The  amebse  are  carried  quite  constantly 
in  the  portal  circulation  to  the  liver,  and  hepatic  abscess  (p.  991)  is  a 
frequent  sequel. 

Symptoms. — The  disease  may  begin  acutely  or  so  insidiously  that 
the  patient  is  unaware  of  its  existence  and  comes  under  the  surgeon's 
care  first  for  the  liver  complication.  A  history  of  residence  in  the 
tropics  is  then  a  great  aid  in  diagnosis,  though  those  who  have  never 
been  in  the  tropics  may  suffer  from  the  disease.  Usually  the  ameba 
may  be  found  in  the  stools,  especially  after  purgation.  The  symptoms 
of  the  acute  stages  are  frequent  and  copious  watery  and  bloody  dis- 
discharges  from  the  bowel,  with  much  pain  and  loss  of  weight  and 
strength."  Periods  of  remission  are  common,  but  recurrence  of  symp- 
toms is  almost  inevitable. 

Treatment. — The  indications  are  (1)  to  destroy  the  parasites  which 
infest  the  bowel,  and  (2)  to  procure  healing  of  the  intestinal  lesions. 
Dieting,  intestinal  antiseptics,  and  rectal  and  colonic  irrigations,  which 
comprise  the  medical  treatment,  rarely  succeed  in  meeting  these 
indications,  though  they  may  secure  alleviation  or  even  latency  of 
symptoms.  If  symptoms  recur  persistently,  it  is  best  to  resort  to  the 
operation  of  cecostomy,  or  that  of  appendicostomy  (Weir,  1902);  when 
a  fistula  is  thus  established  in  the  caput  coli,  irrigations  can  be  much 
more  effectively  used,  and  thus  the  operation  affords  a  means  of  killing 
the  parasites  and  of  curing  the  intestinal  lesions.  Cecostomy  is  done 
by  the  method  of  "Witzel,  for  gastrostomy  (p.  929);  appendicostomy 
is  accomplished  by  detaching  the  meso-appendix  in  part,  and  suturing 
the  appendix  in  the  abdominal  wound  (Fig.  989). 

Pericolitis,  etc. — Of  late  years  numerous  cases  have  been  observed 
at  operation  in  which  there  existed  more  or  less  definite  symptoms  of 
chronic  intestinal  obstruction,  of  chronic  appendicitis,  etc.,  but  in 
which  the  main  pathological  changes  consisted  in  the  presence  of  broad 


PERICOLITIS 


951 


bands  or  membranes,  binding  the  cecum  to  the  parietal  peritoneum, 
holding  the  lower  ileum  in  a  kinked  position,  causing  excessive  angu- 
lation at  the  hepatic  or  splenic  flexures,  or  fixing  the  sigmoid  so  as 
greatly  to  interfere  with  its  function.  These  membranes  were  well 
described  by  Jabez  N.  Jackson  in  1909.  The  kink  of  the  ileum  (Fig. 
959)  is  especially  associated  with  the  name  of  Lane  (1908).  It  is 
usually  assumed,  rather  by  exclusion  than  from  any  definite  reasons, 
that  these  membranes  are  the  result  of  low  grade  infection.  Some 
are  thought  to  be  congenital  in  origin.  But  their  exact  pathogenesis 
is  not  known.  The  subject  has  been  studied  by  Pilcher  (1912)  and 
by  Descomps  (1916). 

Symptoms. — The  symptoms  are  subacute  or  chronic  in  type,  and, 
according  to  Jackson,  consist  essentially  in  pain  and  tenderness,  con- 
stipation, mucous  discharge  from  the  bowel,  meteorism,  loss  of  weight, 
gastric  symptoms,  and  "neurasthenia." 


Fig.  959. — Kink  of  the  ileum  due  to  membrane  binding  it  to  the  cecum,  and  associated 
with  chronic  appendicitis.  The  appendix  was  much  twisted  and  occupied  a  deep  sub- 
cecal fossa.     From  a  patient  in  the  Episcopal  Hospital. 


Treatment. — Treatment  consists  in  division  of  the  adhesions  and 
careful  peritonization  of  all  denuded  surfaces.  A  diseased  appendix  or 
gall-bladder,  or  other  source  of  infection  should  be  treated  appro- 
priately at  the  same  time.  In  cases  of  long  duration,  with  thickened 
cecum  and  ascending  colon,  it  is  best  to  excise  the  entire  affected 
area,   implanting   the   ileum    into   the   transverse   colon    (Fig.   956). 


952 


SURGERY  OF   THE  OASTRO-IXTESTINAL   TRACT 


Neither  a  short-circuiting  operation  (Fig.  957)  nor  unilateral  exclu- 
sion of  the  ascending  colon  |  Fig.  958)  is  satisfactory,  as  trouble  develops 
subsequently  from  distention  of  the  cecum,  owing  to  the  normal 
reversed  peristalsis  in  the  proximal  colon;  and  bilateral  exclusion  of 
the  affected  bowel  (Fig.  960),  though  it  may  prevent  accumulation 
of  secretions  if  a  false  anus  is  established  at  one  or  both  ends  of  the 
excluded  loop,  is  not  much  preferable. 

Pericolitis  Sinistra.  —When  the  sigmoid  is  affected  the  cause  almost 
always  is  inflammation  of  one  or  more  of  the  diverticula  so  commonly 
found  there,  and  the  pathological  changes  are  somewhat  different 
from  those  encountered  about  the  cecum  and  ascending  colon.  The 
classification  I  suggested  in  1907  includes:  (1)  Sigmoiditis,  an  inflam- 
matory hyperplasia  of  the  walls  of  the  sigmoid,  converting  it  into  a 
rigid  tube,  and  usually  causing  a  certain  amount  of  obstruction.    This 


Fig.  960. — Bilateral  exclusion  of  the  ascending  colon,  both  ends  of  the  excluded  bowel 
being  sutured  to  the  skin  and  allowed  to  discharge. 


is  comparatively  rare.  It  may  be  caused  by  inflammation  of  a  diver- 
ticulum buried  in  the  intestinal  wall  or  in  an  epiploic  appendage. 
(2)  Perisigmoiditis,  which  usually  is  the  result  of  inflammation  of  a 
diverticulum  projecting  into  the  free  peritoneal  cavity.  This  may  or 
may  not  lead  to  perforation  or  abscess  formation.  The  symptoms 
resemble  those  of  appendicitis,  except  that  they  occur  on  the  left  side, 
and  the  treatment  is  the  same,  viz.,  excision  of  the  diverticulum  and 
drainage  of  the  abscess,  or  in  rare  cases  resection  of  the  diseased  portion 
of  the  sigmoid,  especially  if  there  is  any  suspicion  of  malignancy. 
Sigmoid  diverticulitis  has  been  particularly  studied  by  Mayo  (1907) 
and  by  Brewer  (1907).  (3)  Mesosigmoiditis :  This  again  is  most  often 
due  to  inflammation  of  a  diverticulum  lying  within  the  layers  of  the 
meso-sigmoid,  or  to  an  ulcer  in  the  sigmoid.  Sometimes  a  distinct 
tumor  is  formed  by  the  secondarily  enlarged  lymph  nodes  (Fig.  961); 


VISCEROPTOSIS 


953 


and  sometimes  the  meso-sigmoid  becomes  contracted  and  distorted, 
causing  secondary  obstructive  symptoms  (Ries,  1907). 

Cecum  Mobile. — An  unduly  mov- 
able cecum  may  be  the  cause  of 
many  of  the  symptoms  just  de- 
scribed, according  to  Wilms  (1908). 
This  condition  may  be  associated 
with  Lane's  kink  or  with  Jackson's 
membrane,  constricting  the  ascend- 
ing colon  or  hepatic  flexure;  and 
is  to  be  treated  by  suspension  of 
the  cecum  by  suture  to  the  parietal 
peritoneum  after  removal  of  the 
appendix  and  any  adventitious 
membrane  present. 


Fig.  962.  —  Pendulous  abdomen; 
complaints  of  backache  and  invalidism 
for  years.     Episcopal  Hospital. 


Fig.  961. — Meso-sigmoiditis,  in  a  child  of 
seven  years.  Recovery  after  exploratory 
laparotomy.      Children's  Hospital. 


Fig.  963. — Same  patient  as  Fig.  962. 
All  symptoms  relieved  by  wearing 
suitable  belt. 


Visceroptosis. — Glenard,  in  1885,  drew  attention  to  general  visceral 
prolapse,  involving  the  hollow  viscera,  usually  the  right  kidney,  and 
sometimes  the  liver  and  spleen  as  well.  The  deformity  is  more  common 
in  women,  and  may  or  may  not  be  associated  with  pendulous  abdomen. 
It  is  recognized  now  as  not  very  rare  in  children,  and  is  often  held 
responsible  for  chronic  constipation.  Gastroptosis,  already  mentioned 
at  p.  923,  usually  is  a  part  of  general  visceral  prolapse.  In  cases  of 
pendulous  abdomen  symptoms  of  sacroiliac  relaxation  (p.   578)  may 


954 


SURGERY  OF  THE  G 'ASTRO-INTESTINAL  TRACT 


arise,  and  much  comfort  often  be  derived  from  the  use  of  an  abdominal 
belt  (Fig.  9(>3)  or  properly  fitting  corset,  though  skiagraphs  made 

(after  the  use  of  an  opaque  meal  by 
mouth  or  enema)  before  and  after 
the  application  of  such  a  support  do 
not  show  any  noticeable  change  in 
the  position  of  the  hollow  viscera. 
Relief  probably  is  secured  by  over- 
coming static  strain  in  the  pelvic 
joints  and  lumbar  spine  or  by  the 
improvement  in  the  circulation  of  the 
ptosed  viscera. 

Chronic  Constipation,  which  often  is 
due  to  some  mechanical  factor,  such  as 
visceroptosis  or  one  of  the  types  of 
pericolitis  above  described,  is  treated 
by  Lane  by  means  of  exclusion  of  the 
colon  by  ileo-sigmoidostomy.1  Owing 
to  the  normal  reversed  peristalsis  in 
the  ascending  colon,  both  it  and  the 
cecum  soon  become  overfilled  with 
feces  after  simple  ileosigmoidostomy; 
so  that  it  is  the  rule  to  excise  the 
colon  from  the  terminal  ileum  to  a 
point  beyond  the  obstruction,  either 
primarily  or  subsequently.  Codman 
warns  against  accepting  without  ques- 
tion the  evidence  of  skiagraphs  made 
after  the  ingestion  of  an  opaque  meal 
as  indicating  true  obstructive  kinks 
in  the  large  intestine,  since  it  has  been 
found  by  Hertz  that  fluoroscopic  ex- 
amination demonstrates  no  obstruction  to  the  onward  course  of  the 
intestinal  contents   even  when  the  kinks   appear   very  pronounced. 

1  According  to  Lane's  theory  most  human  ailments  are  due  to  "chronic  intestinal 
stasis:"  the  primary  condition  is  some  obstruction  in  the  descending  colon  or 
sigmoid;  this  results  in  cecal  dilatation,  and  in  attempts  to  overcome  the  obstruc- 
tion adventitious  attachments  are  formed  around  the  cecum  and  lower  ileum  which 
should  be  regarded  as  nature's  efforts  to  fix  the  bowel  in  a  more  effective  position. 
Unfortunately  this  usually  results  in  obstruction  in  the  lower  ileum;  the  weight 
of  the  retained  secretions  in  the  jejuno-ileum  causes  a  kink  at  the  duodeno-jejunal 
juncture,  and  again  in  an  effort  to  overcome  this  nature  produces  adhesions  around 
the  origin  of  the  jejunum  which  may  increase  the  obstruction,  and  by  leading  to 
dilatation  of  the  duodenum  may  be  responsible  for  the  development  of  duodenal 
ulcer.  Gastro-enterostomy,  Lane  holds,  is  effective  merely  because  suspension  of 
the  first  jejunal  loop  to  the  stomach  relieves  obstruction  at  the  duodeno-jejunal 
juncture;  the  gastro-jejunal  anastomosis  is  of  no  use  whatever.  The  only  rational 
treatment  for  all  these  conditions,  he  contends,  is  section  of  the  lower  ileum  and 
union  of  its  proximal  end  with  the  sigmoid  below  the  last  obstruction.  In  this 
way  he  claims  to  have  cured  such  diverse  lesions  as  exophthalmic  goiter,  tuber- 
culosis of  the  hip,  trifacial  neuralgia,  etc.,  all  of  which  he  attributes  to  a  primary 
auto-intoxication  from  chronic  intestinal  stasis. 


Fig.  964. — Congenital  megacolon. 
From  a  patient  under  the  care  of  the 
late  Prof.  Ashhurst  in  the  University 
Hospital. 


SURGERY  OF  THE  RECTUM  AND  ANUS  955 

In  most  cases  of  chronic  constipation  the  delay  occurs  in  the  pelvic 
colon,  and  not  at  the  hepatic  or  splenic  flexures  where  kinks  are  most 
apparent. 

Congenital  Megacolon. — This  is  believed  by  most  pathologists  to 
be  really  of  congenital  origin,  as  indicated  by  the  name  selected  for 
it  by  Hirschsprung  in  1886.  It  is  also  known  as  Hirschsprung's 
Disease.  Whether  or  not  there  is  always  a  mechanical  obstruction, 
or  whether  the  dilatation  of  the  colon  is  of  neuropathic  origin,  are 
questions  still  in  dispute.  The  sigmoid  flexure  is  usually,  and  the 
entire  colon  often,  involved;  while  the  rectum  and  the  small  intestine 
almost  always  escape  the  dilatation.  Most  patients  come  under 
observation  between  the  ages  of  two  and  ten  years.  Obstinate  con- 
stipation exists  from  very  early  life;  the  abdomen  becomes  immensely 
distended  (Fig.  904);  the  colon  is  packed  with  feces;  tympany  may  be 
extreme  at  times;  and  the  usual  symptoms  of  fecal  impaction  are 
present.  The  general  health  is  impaired,  and  the  child's  growth  may 
be  arrested. 

Treatment. — Treatment  in  mild  cases,  and  especially  in  very  young 
patients,  should  be  palliative,  as  for  any  ordinary  case  of  chronic 
constipation.  In  others,  operative  treatment,  which  offers  the  only 
hope  of  permanent  cure,  should  not  be  delayed  too  long.  Cecostomy 
I  believe  is  the  operation  of  choice;  this  is  to  be  followed  by  free 
irrigations  of  the  bowel  through  the  fistula,  and  when  the  colon  has 
been  well  cleansed  and  the  patient's  health  is  improved,  the  entire 
portion  of  bowel  affected  is  to  be  resected. 

Tumors  of  the  Sigmoid  and  Pelvic  Colon  are  considered  in  con- 
nection with  those  of  the  rectum  (p.  968). 

SURGERY  OF  THE  RECTUM  AND  ANUS. 

Examination  of  the  Anus  and  Rectum. — Digital  examination  may 
be  employed  with  the  patient  on  his  back  with  thighs  flexed,  or  stand- 
ing in  a  stooping  posture.  The  gloved  finger,  well  lubricated  with  green 
soap,  is  gently  insinuated  until  both  sphincters  are  passed,  when  its 
tip  will  be  in  the  rectum,  which  normally  contains  no  feces.  In  men 
the  prostate  and  seminal  vesicles  can  be  felt  beneath  the  anterior 
rectal  wall,  and  in  women  the  cervix  of  the  uterus  usually  can  be  felt. 
Most  pathological  changes  occur  in  or  near  the  anal  canal,  and  they 
often  are  overlooked  because  the  examiner  expects  to  find  them  too 
high  in  the  rectum.  If  visual  inspection  is  desired,  it  is  necessary  to 
dilate  the  sphincter;  this  is  best  done  under  a  general  anesthetic.  First 
one  index  finger  then  the  other  is  introduced,  and  by  gradually  sepa- 
rating them  in  various  diameters,  the  sphincter  is  dilated.  Usually  it 
is  desirable  to  dilate  it  until  the  finger  comes  into  contact  with  the 
tuberosity  of  the  ischium  on  each  side.  The  mere  fact  of  dilatation 
renders  the  anal  canal  visible,  but  to  inspect  the  rectum  high  up,  a 
speculum  (proctoscope)  is  necessary.  Fig.  965  shows  some  conven- 
ient types.     The  patient  should  lie  in  the  Sims  position  (Fig.  1084). 


956 


SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 


The  speculum  is  introduced  gently,  with  the  obturator  in  place, 
and  when  introduced  to  its  full  depth  the  obturator  is  removed, 
any  fecal  matter  or  mucus  is  sponged  away,  and  as  the  speculum  is 
slowly  withdrawn  the  mucosa  which  prolapses  into  its  end  is  care- 
fully inspected  for  ulcers,  dilated  hemorrhoidal  veins,  orifices  of 
fistuhe,  etc.  A  sigmoidoscope  is  similar  to  a  proctoscope,  but  much 
longer  (25  to  35  cm.):  it  is  inserted  with  great  care  until  its  tip  gets 
well  beyond  the  hollow  of  the  sacrum,  and  the  bowel  is  examined 
(by  light  reflected  from  a  head  mirror,  or  preferably  by  means  of 
an  incandescent  bulb  at  the  point  of  the  instrument)  from  above 
downward,  as  the  instrument  is  withdrawn.  In  most  cases  the  instru- 
ment does  not  really  enter  the  sigmoid,  but  the  entire  rectal  canal 
is  readily  seen,  especially  if  the  pelvis  is  raised  so  that  the  rectum 
balloons. 


Fig.  965. — Two  forms  of  proctoscope,  and  a  sigmoidoscope. 


Congenital  Malformations. — These  are  due  to  failure  of  proper 
union  between  the  primitive  proctodeum  and  the  rectum  (Figs.  966, 
967,  and  968).  The  most  important  classification  is  into  those  infants 
with  absolute  occlusion  of  the  rectal  canal,  and  those  in  whom  there 
exists  some  form  of  fistulous  exit  for  the  meconium.  In  these  latter 
cases  the  rectum  may  empty  into  the  urethra  or  the  bladder,  or  in 
the  female  into  the  vagina.  In  all  except  the  last  mentioned  variety 
the  condition  usually  is  recognized  at  birth,  or  within  a  few  days,  and 
demands  immediate  operation.  When  the  opening  is  into  the  vagina 
no  obstruction  may  occur,  and  the  malformation  may  pass  unnoticed 
until  adult  life. 

The  proctodeum  may  be  present,  as  a  dimple  or  shallow  sinus 
at  the  normal  site  of  the  anus,  the  occlusion  being  above;  or  there 
may  be  no  evidence  of  an  anus.  The  most  serious  cases  are  those  in 
which  the  proctodeum  is  present  and  the  occlusion  so  high  in  the 


SURGERY  OF  THE  RECTUM  AND  ANUS 


957 


rectum  or  sigmoid  that  it  cannot  be  recognized  from  below,  but  is 
only  inferred  when  symptoms  of  obstruction  have  been  present  for  a 
number  of  days.  In  such  cases  it  is  safer  to  open  the  cecum  than  the 
sigmoid,  since  the  obstruction  may  be  in  the  latter. 


Fig.    966. — Congenitally   imperforate 
rectum,  proctodeum  absent. 


Fig.  967. — Congenitally   imperforate 
rectum,  proctodeum  present. 


Fig.  968. 


-Congenitally  imperforate  rectum,  the  bowel  opening  into  the  urinary 
tract. 


I  demonstrated  in  1907  that  there  are  exceedingly  few  of  these 
cases  in  which  the  bowel  cannot  be  reached  by  a  perineal  operation; 
and  as  the  mortality  of  this  operation  is  very  much  less  than  that  of 
iliac  colostomy  (Littre's  operation,  p.  943)  which  is  the  usual  sub- 
stitute, it  cannot  be  too  strongly  emphasized  that  perineal  proctoplasty 
almost  always  may  be  successfully  accomplished.  An  antero-posterior 
incision  is  made  in  the  pCrineum,  over  the  normal  site  of  the  anus, 
from  the  base  of  the  scrotum  to  the  coccyx,  and  this  is  deepened, 
keeping  in  the  median  line  and  following  the  curve  of  the  sacrum, 


958 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


until  the  rectal  pouch  is  found.  (I  may  go  further,  and  advise,  with 
Stromeyer,  even  if  the  rectum  cannot  be  found  from  below,  that  the 
peritoneal  cavity  be  opened  through  the  perineum  and  any  distended 
loop  of  lx»\vel  found.)  When  the  bowel  is  found,  it  is  opened,  and 
its  margins  arc  drawn  down  and  sutured  to  the  skin.  In  newborn 
infants  the  promontory  of  the  sacrum  is  only  3  to  5  cm.  distant 
from  the  anus,  and  I  have  on  several  occasions  carried  the  dissec- 
tion  as  far  as  this  and  succeeded  in  finding  the  rectum;  and  none 
of  the  patients  so  treated  (one  of  whom  was  two  weeks  old  when 
brought  for  operation)  has  died.  On  the  other  hand,  the  only  patient 
on  whom  I  have  been  forced  to  do  iliac  colotomy  (cecostomy)  died 
of  inanition;  this  was  a  case  in  which  no  obstruction  could  be  felt  from 
below,  and  where  the  autopsy  showed  there  was  agenesis  of  a  portion 
of  the  sigmoid,  producing  obstruction.  In  cases  where  the  bowel 
opens  into  the  bladder  or  urethra  it  almost  surely  will  be  possible  to 
reach  the  rectal  ampulla  from  below.  If  nothing  more  radical  can  be 
done  the  surgeon  can  at  least  establish  a  common  perineal  opening 
for  feces  and  uirne,  thus  preventing  temporarily  ascending  infection 
of  the  urinary  tract.  When  the  child  is  older  a  more  radical  opera- 
tion may  be  attempted. 

When  the  bowel  opens  into  the  vagina,  it  is  best  to  dissect  the 
rectum  free,  transplant  the  fistulous  opening  in  it  to  the  normal  site 
of  the  anus,  and  repair  the  vaginal  opening  (Rizzoli,  1856). 

Abscess  Around  the  Rectum  and  Anus. — This  is  a  frequent  affection, 
and  the  abscess  may  occur  in  various  situations  (Fig.  969) :  (1)  Sub- 

tegumental  or  perianal,  which  is  be- 
tween the  skin  and  the  external 
sphincter;  (2)  ischiorectal,  the  most 
frequent  of  all,  which  occupies  the 
ischiorectal  fossa,  between  the  skin 
and  the  levator  ani  muscle;  (3)  sub- 
mucous between  the  mucous  mem- 
brane of  the  rectum  and  the  internal 
sphincter;  (4)  pelvi-rectal,  which  de- 
velops above  the  levator  ani  muscle, 
just  outside  the  muscular  wall  of 
the  bowel;  and  (5)  retrorectal,  which 
is  similar  to  the  last  named,  except 
that  it  develops  in  the  hollow  of  the 
sacrum.  As  will  be  seen  by  reference  to  the  diagram  all  of  these 
abscesses  have  their  origin  in  the  region  of  the  anus  between  the 
sphincters,  and  almost  always  they  are  the  result  of  slight  trauma, 
from  hardened  feces,  perhaps  combined  with  exposure  to  wet  and  cold. 
The  patient  complains  of  burning  and  scalding  in  the  rectum  and 
great  pain  on  defecation;  it  pains  bim  to  sit  down;  and  he  may 
have  retention  of  urine. 

Ischio-rectal  Abscess  is  most  frequently  seen  (Fig.  971) .  Examination 
in  the  earliest  stages  shows  merely  a  sense  of  resistance  close  to  the 


Fig.  969. — Perianal  abscesses. 
(See  text.) 


FISTULA  IN  ANO 


959 


sphincter  ani,  with  extreme  tenderness.  Later  the  whole  ischiorectal 
region  on  one  side  may  be  tumefied,  red,  edematous,  and  pitting 
on  pressure-  Occasionally  the  abscess  bursts  spontaneously  into  the 
rectum  (between  the  external  and  internal  sphincters)  or  on  the 
surface;  but  usually  it  is  so  painful  that  surgical  treatment  is  sought 
quite  early.  Treatment  consists  in  opening  the  abscess  by  an  incision 
radiating  from  the  anus  in  the  case  of  very  small  abscess;  or  by  an 
anteroposterior  incision  if  the  abscess  is  large.  The  incision  must  be 
much  longer  than  seems  necessary,  since  it  contracts  very  rapidly 
when  the  pus  is  discharged.  The  cavity  is  drained  by  a  wick  of  gauze, 
and  is  allowed  to  heal  by  granulation.  Great  care  in  dressing  is 
requisite  to  prevent  damming  up  of  pus.  The  affection  is  not  usually 
a  serious  one,  but  I  have  seen  a  few  fatal  cases  in  alcoholics  and  patients 
otherwise  unable  to  withstand  infection.  The  sinus  may  be  very  slow 
in  healing,  and  fistula  in  ano  is  a  frequent  result,  especially  if  rupture 
into  the  bowel  takes  place. 

The  other  forms  of  abscess  mentioned  require  the  same  treatment, 
but  in  those  which  lie  above  the  external  sphincter  (submucous)  it 
is  desirable  to  divide  this  also,  as  in  fistula  in  ano,  to  secure  better 
drainage.  A  pelvi-rectal  abscess  should  be  opened  by  an  incision  in 
the  ischio-rectal  fossa,  after  which  the  abscess  is  freely  opened  and 
drained  by  puncturing  the  levator  ani  and  then  dilating  it  by 
Hilton's  method  (p.  50). 


Fig.  970. — Fistulae  in  ano:  1,  complete  fistula  (usual  form);  2,  blind  external 
fistula  (usual  form);  3,  blind  internal  fistula;  4,  blind  external  fistula  with  suppurat- 
ing tracts;  5,  complete  fistula  entering  the  bowel  above  the  internal  sphincter. 


Fistula  in  Ano. — -The  most  frequent  cause  of  a  fistula  about  the 
anus  is  ischio-rectal  abscess. 

The  fistula  may  have  two  openings,  one  on  the  skin  surface  (usually 
over  the  ischio-rectal  fossa)  and  the  other  on  the  mucous  surface 
(usually  between  the  external  and  internal  sphincters) ;  this  is  known 
as  a  complete  fistula.  Only  one  opening  may  exist,  and  this  may  be 
on  the  skin  surface  {blind  external  fistula),  or  on  the  mucous  surface 
(blind  internal  fistula) .  Sometimes  there  are  two  or  more  skin  openings 
to  the  same  fistula,  which  may  then  resemble  a  horseshoe  in  form. 
Occasionally  several  independent  fistulse  exist. 


960  SURGERY  OF   THE  G ASTRO-INTESTINAL    TRACT 

Symptoms  and  Diagnosis. — The  patient  complains  of  a  discharge  of 
pus,  or  ;ni  irritation  of  the  skin  around  the  anus.  The  external  orifice 
of  the  fistula  usually  is  easily  detected  when  the  buttocks  are  separated ; 
it  may  be  marked  by  a  granulation  or  a  tab  of  skin.  The  internal  orifice 
sometimes  can  be  felt  by  a  finger  in  the  rectum  as  an  indurated  spot,  or 
it  may  lie  made  visible  by  means  of  a  rectal  speculum.  The  suppurat- 
ing tract  which  connects  the  two  may  be  very  devious.  If  it  is  desired 
to  probe  the  fistula  without  giving  a  general  anesthetic,  the  finger 
should  be  introduced  into  the  rectum  before  the  probe  is  passed  into 
the  sinu<.  Every  fistula  around  the  anus  is  not  a  fistula  in  ana;  it 
may  be  a  pilo-nidal  sinus  (p.  297)  or  the  opening  of  a  cold  abscess  in 
connection  with  disease  of  the  pelvic  bones  or  vertebral  column;  or, 
more  probably,  a  fistula  resulting  from  a  peri-urethral  abscess  (p.  1082). 

Treatment. — If  the  fistula  is  of  very  recent  formation,  palliative 
treatment  may  be  employed.  Cauterization  with  silver  nitrate  or 
chloride  of  zinc,  or  injections  of  bismuth  paste  sometimes  bring  tem- 
porary relief,  but  permanent  cure  without  operation  is  very  rare. 
The  classical  operation  consists  in  laying  open  the  fistula  from  one 
orifice  to  the  other,  by  division  of  the  external  anal  sphincter.  A 
grooved  director  is  passed  into  the  external  opening  of  the  fistula,  is 
caught  by  a  finger  as  it  emerges  in  the  anal  canal  or  rectum,  and  its 
point  is  bent  down  and  brought  out  of  the  anus,  which  is  then  slit  up 
on  the  director  as  guide.  In  the  case  of  external  blind  fistulas  the 
director  is  passed  into  the  sinus  and  is  made  to  perforate  the  rectal 
mucous  membrane  where  this  seems  thinnest.  A  blind  internal  fistula 
may  be  opened  up  in  similar  manner  after  exposing  its  internal  orifice. 
When  the  fistula  is  once  laid  open,  the  cicatricial  tissue  lining  it  is 
cut  or  scraped  away,  and  the  raw  surface  is  packed  and  allowed  to 
heal  by  granulation.  The  sphincter  should  be  cut  transversely,  not 
obliquely  to  its  fibers,  and  in  not  more  than  one  place  at  the  same 
operation,  even  if  several  fistulas  exist,  for  fear  of  producing  inconti- 
nence of  feces. 

Of  late  years  many  surgeons  have  had  much  success  in  curing 
fistula  in  ano  by  formal  excision  of  the  tract  followed  by  immediate 
closure  by  buried  absorbable  sutures;  but  the  practice  is  not  yet  very 
common. 

Some  of  these  fistulas  are  tuberculous  in  nature;  usually  they  develop 
very  insidiously,  and  usually  a  tuberculous  focus  exists  elsewhere  in 
the  body.  Unless  the  other  lesions  are  very  far  advanced,  tuberculous 
fistulas  should  be  treated  by  excision  and  suture,  as  those  of  simple 
inflammatory  nature.  Scraping  and  leaving  the  wound  open  is  apt 
to  result  in  recurrence. 

Fissure  of  the  Anus. — If  a  lump  of  hardened  feces  tears  down  one 
of  the  anal  valves,  the  trauma  is  very  apt  to  result  in  an  indolent  ulcer, 
lying  in  the  grasp  of  the  external  sphincter.  The  ulcer  is  placed 
longitudinally  in  the  anal  canal,  almost  always  at  its  posterior  mid- 
portion,  and  usually  extends  on  to  the  skin  surface.  Almost  unbearable 
burning  pain  at  the  anus,  after  every  act  of  defecation,  and  lasting 


FISTULA   AND  FISSURE  OF   THE  ANUS  961 

for  an  hour  or  more,  is  a  highly  characteristic  symptom;  and  inspection 
of  the  anus  confirms  the  diagnosis.  Digital  examination  of  the  anal 
canal  should  not  be  made  until  the  surgeon  is  ready  to  treat  the  lesion. 
Very  occasionally  a  recently  formed  fissure  can  be  made  to  heal  by 
cauterization,  application  of  a  stimulating  ointment,  and  scrupulous 
cleanliness;  but  in  most  cases  operation  is  required.  This  consists 
in  division  of  the  sphincter  through  the  base  of  the  ulcer,  under  a 
general  anesthetic.    Healing  is  then  prompt  under  ordinary  dressings. 

Hemorrhoids  or  Piles. — A  varicose  condition  of  the  rectal  veins  is 
a  very  frequent  affection.  The  inferior  hemorrhoidal  veins  drain  into 
the  internal  pudic;  the  middle  hemorrhoidals  into  the  internal  iliac  or 
one  of  its  branches;  while  the  superior  hemorrhoidals  are  tributaries 
of  the  portal  system  through  the  inferior  mesenteric  vein.  These 
veins  lie  beneath  the  mucosa  in  loose  areolar  tissue,  possess  no  valves, 
and  are  therefore  especially  subject  to  the  effects  of  gravity;  there  are 
free  anastomoses  between  the  superior  and  the  middle  and  inferior 
hemorrhoidal  veins,  so  that  dilatation  of  one  set  is  quickly  succeeded 
by  dilatation  of  the  others.  In  addition  to  the  effect  of  gravity,  which 
is  always  acting,  these  veins  are  liable  to  distention  from  the  pressure 
of  the  contents  of  the  rectum  and  sigmoid,  from  disturbances  in  the 
portal  circulation  (which  occur  during  every  period  of  digestion,  and 
which  pathological  states  frequently  render  constant),  and  from 
pressure  on  the  pelvic  veins  in  cases  of  ovarian,  uterine,  or  prostatic 
disease.  Straining  in  urination  (as  from  stricture)  as  well  as  that 
due  to  chronic  constipation,  is  a  frequent  cause. 

Hemorrhoids  are  classed  as  internal  (which  are  covered  with  mucous 
membrane)  and  external  (covered  by  skin),  or  as  inter o-external, 
according  to  their  relation  to  the  sphincters.  Hemorrhoids  are  further 
classed  as  bleeding,  inflamed,  thrombosed ,  etc.,  terms  which  sufficiently 
explain  themselves. 

The  affection  is  commonest  in  adults,  but  is  not  very  rare  in  the  young 
and  the  aged.  External  piles  appear  as  protrusions  of  small  size,  close 
around  the  anus;  they  are  covered  with  normal  skin,  unless  inflamed, 
when  they  become  purplish  or  red,  swollen  and  very  tender  (Fig.  971). 
Suppuration  may  occur,  and  clotting  of  the  contained  blood  is  not 
very  unusual;  in  this  way  a  phlebolith  may  develop.  The  skin  around 
the  anus  may  become  much  macerated,  and  at  first  glance  the  condition 
may  be  mistaken  for  mucous  patches;  but  the  latter  usually  are  not  the 
only  signs  of  syphilis  present,  and  frequently  occur  elsewhere  as  well 
as  around  the  anus.  Internal  piles  are  arranged  in  a  circle  just  within 
the  sphincters.  Three  sites  are  constant:  two  on  the  right  of  the  anus, 
and  one  on  the  left;  and  such  piles  are  termed  primary.  Secondary 
piles,  not  always  present,  and  never  more  than  four  in  number  (Miles, 
1919)  may  develop  at  other  points  of  the  anal  circumference.  Piles 
are  bluish-black  protrusions  beneath  the  mucous  membrane,  and  are 
easily  compressible  unless  partly  organized  or  thrombosed  from 
repeated  attacks  of  inflammation.  The  piles  become  worse  when  the 
patient  is  constipated,  and  may  protrude  only  when  he  strains  at 
61 


962 


SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 


stool  or  may  come  down  on  the  slightest  effort  (Fig.  972),  leading 
eventually  to  prolapse  of  the  rectum.  There  is  a  sense  of  fulness  and 
discomfort  in  the  rectum  almost  all  the  time,  and  during  a  "fit  of  the 
piles,"  when  these   structures  become  inflamed,  the  pain  may  be 

almost  unendurable  and  may 
radiate  in  various  directions. 
Free  bleeding  from  the  dilated 
veins  usually  brings  relief,  and  is 
a  rather  frequent  occurrence,  es- 
pecially at  the  end  of  a  bowel 
movement.  The  blood  is  bright 
red,  and  appears  spread  over  the 
fecal  masses,  not  mingled  with 
them,  as  is  blood  which  comes 
from  higher  up  in  the  intestinal 
tract,  and  which  is  apt  to  be 
brown  and  clotted  before  it  is 
passed. 

Treatment.- — Any  cause  which 
can  be  discovered  should  be  re- 
moved if  possible.  In  mild  cases 
it  is  sufficient  to  attend  to  the  state  of  the  bowels,  procuring  at 
least  two  free  and  soft  motions  daily  by  means  of  dieting  and 
mild  laxatives,  such  as  salines  in  the  morning,  senna,  rhubarb, 
etc.  Active  purges  have  little  therapeutic  effect  though  they  may 
be  required  to  unload  the  rectum.  Scrupulous  cleanliness  must 
be  preserved  by  irrigation  or  injections  of  cold  water;  protruding 


Fig.  971. — Inflamed    hemorrhoids    and 
ischiorectal  abscess.     Episcopal  Hospital. 


Fig.  972. — Internal  hemorrhoids,  protruding  and  bleeding.     Episcopal  Hospital. 


piles  should  be  pushed  back  after  defecation;  and  some  astringent 
ointment  (as  one  of  equal  parts  of  gall  and  stramonium  ointment, 
U.  S.  P.)  may  be  applied  to  the  anus.  Should  inflammation  occur, 
the  patient  should  be  confined  to  bed,  with  the  pelvis  slightly  elevated ; 


HEMORRHOIDS  963 

and  an  ice  bag  or  dry  hot  cloths  may  be  applied  locally.  Moist  heat 
should  be  avoided.  Much  relief  may  be  secured  by  the  administration 
of  the  following:  1$ — Ext.  rhamni  pursh.fi.,  15.  c.c;  ext.  ergot.fi.,  30  c.c. 
ext.  hamamelis  fl.,  45  c.c. — M.  S. —  Teaspoonful  in  water  three  or  four 
times  daily.  Sometimes  suppositories  of  opium,  with  acetate  of  lead 
or  tannic  acid,  prove  useful.  If  thrombosis  occurs  and  the  pile  is 
excessively  painful,  it  may  be  punctured  and  the  clot  evacuated. 
Usually  it  is  best  to  postpone  more  formal  operative  treatment  until 
the  inflammation  has  subsided.  Some  surgeons  employ  palliative 
operations,  especially  the  injection  of  carbolic  acid  into  the  base  of 
each  of  the  piles  (one  or  two  at  each  sitting)  which  are  thus  thrombosed 
and  may  eventually  shrivel  up.  I  have  no  experience  with  this  method 
myself,  but  believe  that  as  commonly  employed  it  is  neither  efficient 
nor  entirely  safe.  Wallis  prefers  a  10  per  cent,  solution  of  carbolic 
acid  in  glycerin  and  water;  3  to  8  minims  are  injected  into  the  pile, 
according  to  its  size.    He  found  his  patients  secured  temporary  relief. 

The  operations  in  common  use  for  cases  of  hemorrhoids  are  ligation 
and  the  clamp  and  cautery  operation.  For  the  average  operator  there 
is  no  doubt  that  the  first  of  these  is  the  method  of  choice  both  for 
safety  and  for  certainty  of  cure.  For  internal  hemorrhoids  I  think 
it  is  preferable  to  cauterization,  though  the  latter  is  widely  employed 
for  these  as  well  as  for  external  piles.  Excision  (Whitehead,  1882)  is 
a  more  formidable  operation,  is  quite  unnecessary  as  it  is  often  a  failure 
and  the  simpler  operations  are  always  curative  if  properly  done. 

Ligation  of  Hemorrhoids. — The  anus  is  dilated  as  described  at  p.  955, 
and  each  pile  mass  is  caught  in  suitable  forceps.  Hemostatic  forceps 
are  not  efficient,  as  they  usually  tear  loose.  The  Allis  forceps  or  a 
special  ring  forceps  may  be  used.  Unless  all  the  piles  are  clamped 
in  this  way  at  one  time,  there  will  be  danger  of  dislodging  the  ligatures 
already  placed  while  the  remaining  piles  are  being  sought  for.  If  there 
is  any  pile  which  has  a  cutaneous  margin  (intero-external  hemorrhoid) 
a  groove  should  be  cut  around  its  base  through  the  skin  with  scissors; 
this  prevents  the  ligature  from  slipping,  and  by  severing  the  skin 
nerves  reduces  the  discomfort  after  operation.  A  groove  may  be 
cut  also  in  the  mucous  membrane,  all  around  the  base  of  the  pile, 
exposing  its  pedicle,  but  this  is  not  necessary.  Then  a  curved  needle 
carrying  a  long,  stout,  linen  thread  is  made  to  transfix  the  base  of  the 
pile,  in  the  long  axis  of  the  rectum;  the  loop  of  the  thread  is  cut  and 
the  pile  is  ligated  in  two  sections,  the  ligatures  interlocking  and  being 
tied  in  the  groove  already  cut.  The  protruding  portion  of  the  hem- 
orrhoid is  then  cut  away  leaving  enough  stump  to  prevent  slipping 
of  the  ligature.  The  ends  of  the  latter  should  be  left  long  until  it  has 
been  ascertained  that  no  bleeding  occurs.  Each  pile  mass  (usually 
there  are  not  more  than  five)  is  treated  in  the  same  way.  Finally  the 
surfaces  of  the  amputated  piles  are  dusted  with  iodoform  powder,  and 
a  sterile  pad  is  applied  to  the  anus  and  held  in  place  by  a  T-bandage. 
Usually  the  bowels  move  spontaneously  by  the  fourth  day.  If  they 
do  not  they  should  be  opened  by  a  dose  of  castor  oil.    An  enema  should 


964  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

not  be  given.  Particular  attention  to  local  cleanliness  and  efficient 
drying  should  be  enforced  for  two  weeks;  usually  the  patient  may 
leave  bed  in  a  week  or  ten  days  after  operation. 

Clamp  and  Cautery  for  Hemorrhoids. — After  dilating  the  sphincter 
and  grasping  all  the  piles  in  suitable  forceps  as  already  advised  a  special 
pile  clamp  is  applied  to  one  of  the  masses,  in  the  long  axis  of  the 
bowel,  and  is  screwed  so  tight  as  to  crush  the  base  of  the  pile.  The 
protruding  tissue  is  not  cut  away  but  is  cauterized  with  the  cautery 
at  a  dull  (cherry)  red  heat  until  destroyed.  Though  the  pile-clamp 
usually  has  its  under  surface  faced  with  ivory,  to  prevent  radiation  of 
the  heat  to  the  surrounding  tissues,  it  is  well  as  an  additional  safeguard 
to  surround  it  with  damp  cloths  while  the  cautery  is  in  use.  Each 
pile  mass  in  turn  is  treated  in  similar  fashion,  and  subsequent  treat- 
ment is  conducted  as  alreadv  described. 


Fig.  973. — Prolapse  of  rectum.     Children's  Hospital 

Prolapse  of  the  Rectum. — This  develops  as  the  result  of  repeated 
straining  efforts,  as  in  cases  of  hemorrhoids  with  constipation  or  in 
severe  diarrhea  with  rectal  tenesmus,  or  sometimes  as  the  result  of 
whooping-cough.  A  congenital  malformation  in  the  attachment  of 
the  rectum  within  the  pelvis  is  also  recognized  as  a  cause,  the  recto- 
vesical or  rectovaginal  pouch  of  peritoneum  being  abnormally  deep. 
The  loose  mucous  membrane  protrudes  from  the  anus  at  first  only 
during  defecation,  and  may  recede  spontaneously  when  the  patient 
stands  up.  Later,  however,  the  bowel  may  protrude  at  other  times 
and  may  require  to  be  replaced  manually.  Occasionally  reposition 
becomes  impossible;  in  such  cases  usually  the  muscular  wall  of  the 
rectum  has  prolapsed  also  {procidentia  recti). 

The  condition  is  most  common  in  young  children,  but  occurs  also 
in  adults,  and  sometimes  during  old  age  when  it  often  seems  to  depend 
on  loss  of  muscular  tone.  In  every  such  case  examination  should  be 
made  to  exclude  the  presence  of  polypus,  stricture,  or  carcinoma 
higher  up  in  the  bowel. 

Symptoms. — In  the  ordinary  form  (prolapsus  recti  or  partial  prolapse) 
the  mucous  membrane  of  the  rectum  is  seen  protruding  from  the  anus 


PROLAPSE  OF   THE  RECTUM  965 

as  a  red  or  purplish  ring.  Usually  the  condition  is  unmistakable 
(Fig.  973).  In  complete  prolapse  (procidentia)  the  protrusion  may  be 
5  cm.  or  more  in  depth,  and  there  is  a  clearly  recognized  groove  between 
the  mucous  membrane  and  the  anus.  Prolapse  causes  a  sense  of  weight 
and  weakness,  and  often  some  disturbance  of  the  urinary  functions. 
Strangulation  is  rare,  but  is  seen  occasionally  at  the  first  onset  of 
the  prolapse;  when  the  condition  becomes  chronic  the  sphincters 
are  much  relaxed. 

Treatment. — Reduction  usually  may  be  secured  by  moderate  pressure 
with  an  oiled  cloth  or  the  gloved  hand,  while  the  patient  is  lying  prone. 
In  cases  of  strangulation  it  may  be  necessary  to  divide  the  sphincter. 
Recurrence  often  may  be  avoided  by  having  the  bowels  opened  only 
when  the  patient  is  lying  down  flat  on  his  back.  Moreover,  the 
buttocks  should  be  strapped  together  by  adhesive  plaster,  which  is 
removed  only  after  the  bowels  have  acted,  and  is  at  once  replaced 
when  the  parts  have  been  cleansed.  In  the  case  of  most  children,  in 
whom  the  condition  is  not  of  very  long  standing,  a  cure  results  if  the 
child  is  kept  in  bed  with  proper  regulation  of  diet  and  bowels.  Cod- 
liver  oil  is  valuable  as  a  tonic  for  these  purposes.  If  operation  is 
required,  trial  should  first  be  made  of  cauterization  as  in  the  case  of 
hemorrhoids,  clamping,  excising,  and  cauterizing  longitudinal  folds 
of  mucous  membrane  down  to  within  1  or  2  cm.  of  the  anal  margin. 

Mummery's  operation  (1910)  consists  in  opening  the  space  between 
the  rectum  and  sacrum  by  a  transverse  incision,  packing  it  full  of 
gauze,  and  allowing  it  to  heal  by  granulation.  The  patient  should 
remain  in  bed  for  a  month.  Sigmoidopexy ,  or  suspension  of  the 
sigmoid  to  the  anterior  abdominal  wall,  was  first  employed  in  1889 
by  Verneuil;  it  is  wise  to  combine  it  with  a  plastic  operation  below, 
as  recurrence  has  taken  place  in  more  than  half  the  cases  treated  by 
sigmoidopexy  alone  (Pachinio,  1905).  Obliteration  of  the  rectovesical 
(rectovaginal)  pouch  of  peritoneum  is  a  more  efficient  procedure  (Quenu 
and  Duval,  1910;  Moschcowitz,  1912). 

Fecal  Incontinence. — Fecal  incontinence  is  to  be  treated  by  removal 
of  its  cause  when  this  is  possible.  Gersuny  (1893)  dissected  the  anal 
canal  free  of  all  attachments,  and  twisted  it  on  itself  until  a  feeling  of 
resistance  was  encountered;  the  anus  is  then  sutured  in  its  new  position. 
Even  an  iliac  anus  may  be  preferable  to  hopeless  incontinence,  because 
more  cleanly. 

Proctitis. — Inflammation  of  the  rectum  may  be  traumatic  (from 
impaction  of  feces,  frequent  use  of  enemas,  foreign  bodies,  etc.)  or 
infectious  (dysenteric,  septic,  gonococcic,  etc.).  The  symptoms  are 
a  sense  of  heat;  tenesmus;  frequent,  small,  watery  stools,  often  with 
blood  and  mucus.  There  may  be  considerable  fever  and  much  con- 
stitutional disturbance.  Examination  through  a  speculum  shows 
inflamed  mucous  membrane,  and  frequently  patches  of  lymph  covering 
ulcers  which  bleed  readily  when  touched.  Treatment  involves  removal 
of  the  cause  when  this  is  possible  and  known;  also  cleansing  and  anti- 
septic applications  through  a  speculum.    After  an  ordinary  cleansing 


966     SURGERY  OF  THE  GASTRO-INTESTINAL  TRACT 

enema,  in  severe  cases,  the  patient  may  be  etherized,  and  a  2  per  cent, 
solution  of  silver  nitrate  swabbed  all  over  the  inflamed  surfaces, 
through  a  speculum.  Then  the  rectum  is  irrigated  with  boric  acid 
solution  (half  saturated),  and  finally  an  injection  is  given  of  50  to  75 
c.c.  of  some  demulcent  solution  (flaxseed  or  slippery  elm),  contain- 
ing 10  drops  of  laudanum  (Abbe);  this  is  to  be  retained  as  long  as 
possible.  In  most  cases  two  or  three  such  treatments  at  intervals  of  a 
few  days  arrest  the  disease.  But  in  cases  where  colitis  also  exists 
(dysenteric,  tuberculous),  recurrence  is  the  rule  unless  the  ulcers 
above  can  be  made  to  heal  by  appropriate  treatment  (p.  950). 

Strictures  of  the  Rectum. — These  are  a  frequent  result  of  dysenteric 
ulceration  and  of  trauma  in  childbirth  (Fig.  948).  Malignant  ulcera- 
tion causing  obstruction  is  considered  under  the  heading  Tumors  of 
the  Rectum  (p.  968).  Inflammatory  changes  in  neighboring  structures 
(vagina,  broad  ligaments  of  uterus,  pelvic  connective  tissue,  prostate, 
etc.)  frequently  extend  to  the  fibrous  tissue  in  the  layers  of  the  rectal 
wall  and  they  may  cause  a  submucous  or  perirectal  stricture  which  is 
the  same  in  its  effects  as  one  which  arises  in  ulceration  of  the  mucous 
membrane,  since  no  ulceration  of  the  mucous  membrane  which  does 
not  involve  the  fibrous  tissue  can  produce  a  stricture.  Other  causes 
than  those  already  mentioned  are  rare,  though  tuberculous  and 
syphilitic  and  other  specific  ulcerations  and  strictures  do  occur. 
Syphilitic  stricture,  formerly  considered  frequent,  is  now  acknowl- 
edged to  be  quite  rare.  When  these  specific  ulcerations  occur  their 
pathology  is  much  the  same  as  that  of  septic  or  traumatic  ulceration, 
since  secondary  infection  from  the  intestinal  contents  is  the  rule. 

Almost  all  strictures  occur  within  7  to  10  c.c.  of  the  anus;  those 
which  occur  higher,  in  the  sigmoid  or  colon  produce  the  symptoms 
of  chronic  intestinal  obstruction  (p.  942).  The  stricture  may  be 
single  or  multiple,  marginal  or  annular,  of  large  or  small  caliber. 
The  simple  inflammatory  stricture,  according  to  Tuttle,  usually 
occupies  only  a  portion  of  the  circumference  of  the  bowel,  stands  out 
abruptly  from  the  rectal  wall,  usually  is  close  to  the  anus,  and  has  a 
smooth  surface  covered  with  epithelium.  A  syphilitic  stricture 
presents  a  gradual  funnel-shaped  contraction,  there  is  a  bluish-white 
cicatrix  around  the  edges  of  the  ulcer,  and  the  floor  of  the  ulcer  is 
excavated ;  the  edges  of  a  tuberculous  ulceration  always  are  undermined 
and  its  base  is  elevated  (Tuttle).  Secondary  ulceration,  from  fecal 
impaction,  occurs  above  the  stricture,  so  that  when  these  patients 
come  for  treatment  the  rectum  almost  always  is  ulcerated  as  well  as 
strictured,  though  the  ulcers  which  were  the  original  cause  of  the 
stricture  may  have  healed  long  since. 

Symptoms. — These  may  not  develop  for  years  after  the  proctitis 
which  is  the  original  cause  of  the  stricture.  The  patient  may  come 
complaining  of  frequency  of  urination  with  a  sense  of  weight  in  the 
perineum,  and  the  importance  of  thorough  local  examination  cannot 
be  too  often  emphasized.  There  is  a  history  of  the  primary  rectal 
condition,  followed  by  a  latent  period,  and  then  gradually  developing 


STRICTURES  OF  THE  RECTUM  967 

but  steadily  increasing  difficulty  in  obtaining  complete  evacuation  of 
the  rectum.  As  secondary  ulceration  develops,  blood  and  mucus  are 
discharged  with  the  stools,  or  frequently  alone,  the  stricture  retaining 
the  fecal  mass  above  it.  The  diagnosis  of  simple  from  malignant 
stricture  is  made  by  observing  the  long  duration  of  the  simple 
stricture  and  the  comparatively  slight  impairment  of  the  general 
health;  and  by  direct  examination  of  the  rectum,  when  the  smooth, 
hard,  but  not  nodular  character  of  the  stricture  determines  it  to  be 
non-malignant.  Malignant  stricture  is  very  rare  before  thirty-five  or 
forty  years  of  age;  its  course  is  rapid  and  progressive  (two  to  three 
years) ;  loss  of  flesh  and  strength  appears  early ;  the  tumor  is  nodular 
to  the  touch  and  bulges  into  the  lumen  of  the  bowel  as  well  as  causes 
fibrous  thickening  of  its  coats;  and  the  odor  of  the  discharge  is 
gangrenous,  never  simply  fecal  (Tuttle). 

Treatment. — Permanent  cure  cannot  be  hoped  for  from  palliative 
treatment  with  rectal  bougies;  they  are  of  benefit  even  temporarily 
only  when  the  stricture  is  of  recent  formation;  they  must  be  passed 
at  intervals  throughout  the  patient's  life;  and  in  many  cases  serve 
only  to  aggravate  the  patient's  discomfort  by  producing  bleeding 
and  further  ulceration,  even  if  skilfully  and  gently  passed.  An 
ordinary  wax  candle,  molded  by  heat  to  suitable  shape,  makes  as 
good  a  bougie  as  any,  provided  the  stricture  is  not  very  small  and 
is  close  to  the  anus.  In  other  cases  it  is  best  to  use  the  hollow  bougie 
of  Wales,  which  is  introduced  through  a  speculum  passed  up  to  the 
face  of  the  stricture,  and  by  means  of  which  irrigation  may  be  practised 
above  the  stricture.  Before  operative  treatment  is  undertaken  it  is 
important  to  cleanse  the  bowel  above  the  stricture.  If  this  cannot  be 
accomplished  from  below  (by  repeated  enemas  or  colonic  irrigations 
through  a  Wales's  bougie,  aided  by  the  use  of  olive  oil  or  gentle  saline 
purges  by  mouth),  it  is  necessary  to  do  colostomy  (sigmoidostomy). 
After  the  entire  fecal  current  has  been  diverted  in  this  manner,  and 
the  lower  segment  of  the  bowel  thoroughly  evacuated  and  brought 
into  a  healthy  state  by  irrigations,  direct  treatment  of  the  strictures 
may  then  be  attempted.  Posterior  proctotomy  (Verneuil),  or  incision 
of  the  posterior  rectal  wall,  including  the  sphincters  and  everything 
down  to  the  bone,  is  not  to  be  recommended  unless  the  stricture  is 
close  to  the  anus ;  but  it  is  a  good  operation  in  cases  where  septic  proc- 
titis accompanies  stricture,  as  it  secures  free  drainage  and  relieves 
the  acute  symptoms  though  it  does  not  produce  a  cure.  The  hemor- 
rhage is  not  alarming  and  may  be  controlled  by  packing  gauze 
around  a  large  rectal  tube.  It  is  necessary  to  continue  the  passage  of 
bougies  subsequently  for  an  indefinite  period.  In  the  case  of  a  single 
high  stricture  it  may  be  possible  to  perform  sigmoido-proctostomy, 
making  an  anastomosis  by  the  Murphy  button  between  the  sigmoid 
and  the  rectum  below  the  stricture;  the  spur  between  the  strictured 
and  the  anastomotic  opening  may  be  removed  later  by  Dupuytren's 
enterotome.  In  the  worst  cases  of  stricture  formal  excision  of  the 
rectum,  as  for  malignant  disease,  is  the  most  satisfactory  treatment. 


968  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

Recto-urinary  and  Recto-genital  Fistulae. — Formerly  these  were 
frequent  results  of  difficult  parturition,  following  the  separation  of 
sloughs  caused  by  pressure  of  the  fetal  head  or  by  instruments;  but 
owing  to  improvements  in  the  obstetric  art  they  are  now  comparatively 
rare.  Occasionally  they  result  from  operative  injury,  or  from  the 
rupture  of  an  abscess  into  both  the  intestinal  and  genito-urinary  tract, 
or  as  the  result  of  specific  or  malignant  ulceration.  The  fistula  may 
connect  the  intestinal  tract  with  the  bladder  or  urethra  (recto-vesical 
and  recto-urethral  fistula)  or  with  the  vagina  (recto-vaginal),  rarely  the 
uterus  (recto-uterine  fistula) .  Vesico-vaginal  and  vesico-uterine  fistula 
are  results  of  similar  causes  and  require  similar  treatment,  though 
the  intestinal  tract  is  not  involved.  The  diagnosis  is  made  by  observing 
the  discharge  of  urine  or  feces  (sometimes  only  of  flatus)  through  an 
abnormal  channel,  and  by  direct  examination  with  sound  or  endoscopic 
instrument  (cystoscope,  proctoscope)  in  the  bladder  or  rectum.  The 
only  satisfactory  treatment  is  by  operation,  which  consists  essentially 
in  dissecting  up  the  borders  of  the  fistula  and  closing  the  opening  in 
the  wall  of  each  viscus  involved,  by  means  of  separate  sutures.  In 
the  rare  cases  of  recto-uterine  or  vesico-uterine  fistulse  hysterectomy 
may  be  necessary  (Chapter  XXIX). 

Tumors  of  the  Rectum  and  Sigmoid. — Benign  tumors  are  com- 
paratively rare.  Adenoma  is  the  least  unusual.  It  occurs  most  often 
in  children  in  the  form  of  rectal  polypus,  and  presents  symptoms 
similar  to  those  of  hemorrhoids,  for  which  or  for  prolapsus  it  is  often 
mistaken.  Usually  when  the  child  strains  the  polypus  comes  down  in 
reach  of  the  examining  finger,  or  it  may  prolapse  through  the  anus. 
Treatment  consists  in  excision  after  transfixion  and  ligation  of  its 
base.  In  adults  adenoma  and  papilloma  are  quite  rare  growths,  and 
usually  are  pre-carcinomatous  in  nature.  The  tumor  is  rather  soft, 
seldom  is  ulcerated,  and  is  freely  movable  on  the  underlying  rectal 
wall.  It  should  be  freely  excised.  In  the  disease  known  as  multiple 
adenoma  the  entire  colon  may  be  invaded  by  small  polypoid  growths, 
though  usually  the  rectum  is  the  part  most  involved.  The  symptoms 
are  persistent  bloody  diarrhea,  with  tenesmus,  and  gradual  loss  of 
flesh  and  strength.  If  removal  of  the  numerous  rectal  growths  is 
followed  by  their  persistent  recurrence,  or  if  there  is  a  suspicion  of 
malignancy  excision  of  the  rectum  should  be  done;  or  if  the  entire 
colon  is  diseased  a  false  anus  may  be  established  in  the  cecum. 

Carcinoma.- — Carcinoma  is  the  most  frequent  tumor  of  the  rectum. 
It  occurs  (1)  at  the  anus  (squamous-celled  carcinoma),  which  is  rare; 
(2)  just  above  the  sphincters  (adeno-carcinoma,  often  encephaloid), 
which  is  not  unusual;  or  (3)  above  the  reach  of  the  examining  finger 
in  the  upper  rectum  or  pelvic  colon,  at  the  level  of  the  promontory  of 
the  sacrum  (adeno-carcinoma,  often  scirrhus);  in  this  latter  situation 
about  two-thirds  of  rectal  cancers  are  found.  The  rectum  frequently 
is  invaded  by  carcinoma  originating  elsewhere  (prostate,  cervix  uteri) . 
Anal  carcinoma  causes  secondary  invasion  of  the  inguinal  lymphatics, 
and  clinically  resembles  epithelioma  of  the  lower  lip.     True  rectal 


TUMORS  OF  THE  RECTUM  969 

carcinoma  extends  in  the  submucous  tissues  of  the  rectal  wall  rather 
than  directly  through  it  to  neighboring  structures;  and  invades  the 
lymph  nodes  in  the  hollow  of  the  sacrum,  but  seldom  higher  than  the 
promontory  of  the  sacrum.  Except  in  the  more  highly  malignant 
forms,  death  is  more  apt  to  occur  from  intestinal  obstruction  than 
from  local  extension  or  metastasis. 

Symptoms. — The  symptoms  are  hemorrhage  (especially  in  younger 
patients),  alternating  diarrhea  and  constipation,  and  eventually  loss 
of  weight  and  foul  discharge  with  highly  characteristic  odor.  These 
symptoms,  however,  may  not  appear  for  months  after  the  development 
of  the  tumor,  particularly  if  the  latter  is  high  in  the  rectum.  Often 
the  growth  is  found  absolutely  inoperable  when  no  symptoms  of  note 
have  ever  existed. 

Diagnosis. — Diagnosis  is  not  difficult  at  the  stage  when  most 
patients  consult  a  surgeon.  The  tumor  is  irregular  in  outline,  nodular, 
with  raised  margins  and  ulcerated  center;  and  it  is  fixed  to  the  bowel 
wall  if  not  to  the  surrounding  structures.  If  any  doubt  exists,  a  piece 
should  be  excised  from  the  base,  for  microscopical  study.  If  the 
growth  is  too  high  to  be  accessible  for  diagnosis  from  below,  lapar- 
otomy should  be  done. 

Treatment. — The  first  question  to  decide  is  whether  or  not  radical 
operation  can  be  done,  and,  if  this  is  impossible,  whether  the  establish- 
ment of  a  false  anus  will  promote  the  patient's  comfort.  The  growth 
may  be  considered  inoperable  (1)  when  the  patient's  condition  forbids 
an  operation  with  a  mortality  varying  from  10  to  50  per  cent.;  (2) 
when  the  growth  is  found  to  be  fixed  even  when  examined  under 
anesthesia;  or  (3)  when  distinct  metastases  exist.  In  such  cases 
palliative  treatment  aims  to  reduce  the  amount  of  fecal  discharge 
and  decrease  its  irritating  qualities  by  attention  to  diet  and  adminis- 
tration of  intestinal  antiseptics;  to  secure  free  evacuation  of  the 
bowels  by  gentle  purging  and  by  enemas  administered  if  possible  by 
a  tube  passed  above  the  growth;  by  local  treatment  of  the  ulcerating 
area  by  irrigation  with  permanganate  or  creolin  solution;  and  finally 
to  keep  the  patient  as  comfortable  as  possible  by  administering  plenty 
of  opium.  In  rare  instances  advantage  is  to  be  derived  from  scraping 
and  cauterizing  the  surface  of  a  cauliflower-like  growth.  The  degree 
of  heat  may  be  controlled  by  placing  a  finger  within  the  bladder 
through  an  abdominal  incision  (D.  F.  Jones,  1915).  If  acute  obstruc- 
tion occurs  (it  is  rare  except  in  carcinoma  of  the  sigmoid),  a  false 
anus  should  be  established  in  the  sigmoid,  or  if  the  obstruction  has 
existed  very  long,  in  the  cecum,  where  the  gut  is  healthier.  Unless 
obstruction  is  present  or  death  only  a  matter  of  a  few  months,  many 
patients  will  prefer  to  suffer  rather  than  be  relieved  at  the  expense  of 
an  iliac  anus;  but  if  the  latter  is  properly  constructured  and  cared  for, 
it  produces  very  little  disability,  and  relieves  the  patient  of  untold 
discomfort  by  producing  latency  of  rectal  symptoms. 

Formation  of  a  False  Anus. — Through  a  left-sided  McBurney 
incision  a  loop  of  sigmoid  is  drawn  out,  and  its  afferent  limb  drawn 


070 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


taut.  If  this  precaution  is  neglected  prolapse  of  the  descending  colon 
may  occur  through  the  false  anus.  Then  the  afferent  and  efferent 
loops  are  stitched  together  along  their  mesenteric  borders,  for  a  dis- 
tance of  about  10  cm.,  so  as  to  form  an  efficient  spur.  The  loop  of 
bowel  is  then  replaced  and  sutured  in  the  abdominal  wound  at  the 
level  of  the  mesentery  (Fig.  974),  a  rubber  tube,  transfixing  the 
mesosigmoid  at  the  apex  of  the  loop,  being  left  in  place  a  few  days  to 
prevent  the  loop  from  retracting  too  far  within  the  abdomen.  If  the 
operation  is  done  for  acute  obstruction  a  Paul's  tube  should  be  fixed 
in  the  proximal  loop  immediately.  Otherwise  it  is  not  necessary  to 
open  the  gut  for  several  days;  the  opening  is  then  accomplished  by 
a  transverse  incision  by  cautery.  Subsequent  treatment  involves 
occasional  irrigation  of  the  rectal  loop  through  the  false  anus,  to  clear 
it  of  discharges  (which  are  much  diminished  after  diversion  of  the 
feces  from  the  ulcerating  area)  and  regular  daily  irrigation  of  the  colon 
through  the  upper  opening.  If  the  colon  is  thoroughly  flushed  out 
every  morning,  by  500  to  1000  c.c.  of  warm  water,  and  if  this  injection 
is  retained  for  about  twenty  minutes,  free  evacuation  of  the  bowel  is 
secured  by  turning  face  downward  and  exerting  pressure  over  the 
cecum.  "The  patient  is  then  quite  comfortable  and  clean  for  the 
rest  of  the  day"  (Wallis,  1912). 


Fro.  974. — Establishment  of  a  permanent  false  anus  by  suturing  the  afferent  and 
efferent  loops  together  "en  canon  de  fusil."    A  Paul's  tube  has  been  tied  in  each  end. 

Radical  Operation. — About  a  week  is  required  to  get  the  intestinal 
tract  in  proper  shape  for  operation,  and  commencing  the  night  before 
large  doses  of  deodorized  tincture  of  opium  should  be  given  (Tuttle). 
In  cases  of  acute  obstruction,  or  if  the  sphincters  will  have  to  be 
removed,  a  preliminary  colostomy  (as  above  described)  should  have 
been  done  about  two  weeks  before  radical  operation.  Opportunity 
should  also  have  been  taken,  when  the  abdomen  was  opened,  to  palpate 
the  liver  for  metastatic  growths. 

1.  Where  the  growth  invades  the  sphincters,  these  and  the  rectum  as 
high  as  the  sacral  promontory  are  removed;  and  the  pelvic  end  of  the 


CARCINOMA  OF  THE  RECTUM  971 

rectum  is  closed  and  allowed  to  drain  through  the  previously  estab- 
lished iliac  anus.  The  perineal  wound  is  completely  closed,  with 
drainage  to  the  hollow  of  the  sacrum.  The  inguinal  lymphatics  should 
be  extirpated  also. 

2.  For  a  growth  just  above  the  anus,  in  which  the  sphincters  can  be 
preserved,  I  think  the  perineal  operation  as  modified  by  Peck  (1909) 
should  be  done:  The  anus  is  closed  by  a  purse-string  suture;  then  an 
incision  is  made  from  coccyx  to  rectum  and  is  carried  forward  on  each 
side  of  the  anus  in  Y-shape.  The  coccyx  may  be  excised,  but  further 
removal  of  bone  from  the  sacrum  (Kraske,  1885)  does  not  materially 
facilitate  the  operation.  Both  of  the  levator  ani  muscles  are  cut  just 
above  the  anus;  the  rectum  is  separated  all  around  its  circumference 
and  is  doubly  ligated  below  the  growth,  divided  between  the  (linen) 
ligatures  and  the  cut  surfaces  are  seared  with  the  actual  cautery. 
The  peritoneum  is  then  opened,  the  rectum  is  freed  anteriorly  from 
bladder  and  prostate,  as  well  as  laterally  and  posteriorly,  and  is  drawn 
down  until  an  area  well  above  the  growth  is  exposed.  It  is  here  again 
doubly  ligated,  divided  and  cauterized,  and  the  tumor  is  removed. 
The  occluding  suture  is  then  removed  from  the  anus,  the  sphincter  is 
split  posteriorly,  and  the  anal  mucous  membrane  is  excised.  The 
proximal  segment  of  bowel,  still  closed  by  ligature,  is  then  drawn 
down  until  it  projects  well  beyond  the  sphincter,  which  is  sutured 
around  it.  The  peritoneum  and  levatores  ani  are  then  repaired,  the 
hollow  of  the  sacrum  is  drained,  and  the  unopened  bowel  is  left  pro- 
truding from  the  anus.  When  several  days  have  passed,  and  granula- 
tion has  begun,  so  that  little  fear  of  infection  remains,  the  redundant 
bowel  (perhaps  sloughing  in  parts)  is  cut  away,  and  fecal  discharge  is 
allowed.  Fair  sphincter  control  is  preserved;  the  immediate  mortality 
of  such  an  operation  is  from  10  to  20  per  cent.;  and  from  20  to  60  per 
cent,  of  patients  pass  the  three-year  interval  without  recurrence. 

3.  For  high  rectal  carcinoma  (all  tumors  above  easy  reach  of  the 
finger),  a  combined  abdominal  and  perineal  extirpation  is  the  accepted 
procedure,  though  the  primary  mortality  even  in  skilled  hands  is 
very  high  (25  to  50  per  cent.),  and  the  permanent  cures  average 
only  about  16  per  cent.  This  method  was  first  introduced  by  Maun- 
sell,  and  has  been  popularized  in  France  by  Quenu  and  Hartmann 
(1897),  and  in  this  country  by  Tuttle  and  the  Mayos.  I  believe  Weir's 
modification  (1901)  of  the  method  in  which  the  sphincter  is  preserved, 
and  which  since  1914  has  been  employed  also  by  Quenu,  is  better  than 
the  original  plan  of  Quenu  in  which  the  entire  rectum  is  removed 
and  an  iliac  anus  established.  Quenu  and  Schwartz  (1917)  have 
reported  7  radical  operations  by  this  method  with  only  1  death.  The 
surgeon  commences  by  opening  the  abdomen  in  the  midline  and 
examining  the  parts.  If  the  tumor  is  high  enough  in  the  sigmoid 
an  ordinary  intestinal  resection  may  be  done,  with  end-to-end  union, 
or  where  possible  by  lateral  anastomosis,  which  is  safer.  If  the 
tumor  is  too  low  to  make  this  possible,  the  sigmoid  is  divided  a  safe 
distance  (15  cm.)  above  the  growth,  both  ends  being  closed  at  once 


972 


SURGERY  OF   THE  CASTRO-INTESTINAL   TRACT 


Fig.  975. — Abdomino-anal  operation  for  carcinoma  of  the  rectum:  the  sigmoid  has 
been  divided  and  both  ends  closed;  the  rectum  has  been  freed  from  the  hollow  of  the 


Fig.  976. — Blood-supply  of  the  pelvic  colon  and  rectum:  1,  ligature  on  the  superior 
hemorrhoidal  artery;  2,  ligature  on  the  inferior  mesenteric;  3,  ligature  on  a  descending 
branch  of  the  left  colic  artery. 


CARCINOMA   OF   THE  RECTUM  973 

by  suture.  The  mesorectum  is  then  divided,  and,  after  ligation  of 
the  superior  hemorrhoidal  artery,  the  rectum  and  fatty  and  lymphatic 
tissue  behind  it  can  be  stripped  off  the  sacrum  quickly,  and  with  very 
little  hemorrhage  (Fig.  975).  The  rectum  is  then  doubly  clamped 
below  the  growth,  divided,  cauterized,  and  the  diseased  bowel 
removed.  Next  the  sigmoid  and  perhaps  the  descending  colon  must 
be  freed  sufficiently  to  enable  the  remaining  bowel  to  be  brought 
down  to  the  anus.  This  is  accomplished  by  mobilization  of  the  sigmoid 
(P.  Duval,  1902) :  the  outer  leaf  of  the  meso-sigmoid  is  divided,  and 
the  bowel  is  turned  toward  the  median  line  by  gauze  dissection, 
restoring  it  to  the  condition  which  existed  in  intra-uterine  life.  By 
ligation  and  section  of  the  sigmoid  arteries,  and  if  necessary  of  the 
inferior  mesenteric  itself,  close  to  the  root  of  the  mesosigmoid  (Fig. 
976)  sufficient  circulation  is  preserved  through  the  loops  of  communica- 
tion from  the  left  colic  or  even  from  the  middle  colic  artery  (Archibald, 
1908).  Ample  slack  of  sigmoid  and  descending  colon  having  been 
secured  in  this  manner,  an  assistant  introduces  forceps  into  the  anus 
from  the  perineum,  and  evaginates  the  lower  segment  of  the  rectum; 
next  he  pulls  down  through  its  lumen  the  upper  segment  (sigmoid). 
The  abdominal  wound  is  then  closed,  after  repair  of  the  pelvic  peri- 
toneum. The  evaginated  rectum  and  sigmoid  are  then  securely  sutured 
together,  and  are  finally  replaced  in  the  pelvis  by  reducing  the  evagina- 
tion.  Drainage  of  the  pelvis  is  provided  by  an  incision  in  front  of 
the  coccyx. 

If  an  iliac  anus  has  been  made  previously,  for  obstruction  or  any 
other  reason,  it  is  better  to  excise  the  entire  rectum,  including  the 
sphincters,  and  to  close  the  perineum. 


CHAPTER   XXIV. 

SURGERY  OF  THE  GALL-BLADDER,  LIVER,  PANCREAS, 

AXI)  SPLEEN. 

SURGERY   OF   THE    GALL  BLADDER    AND   BILE-DUCTS. 

Infections  of  the  Gall-bladder  and  Bile-ducts. — It  has  been  shown 
by  Adami  and  others  that  bacteria  are  constantly  being  transmitted 
from  the  intestinal  tract  through  the  portal  circulation  to  the  liver. 
The  liver  is  endowed  with  antibacterial  and  antitoxic  properties, 
and  under  normal  conditions  the  bacteria  received  in  the  way  described 
are  destroyed  in  the  liver.  But  if  the  virulence  of  the  bacteria  is 
increased,  or  the  destructive  action  of  the  liver  lessened,  then  such 
bacteria  are  excreted  from  the  liver  with  the  bile.  The  gall-bladder  is 
a  suitable  place  for  bacteria  to  multiply,  both  from  its  anatomy,  and 
from  certain  characteristics  which  are  easily  acquired.  The  bile  tends 
to  stagnate  in  the  gall-bladder  because  of  the  tortuosity  of  the  cystic 
duct,  because  the  fundus  of  the  gall-bladder  is  lower  than  its  outlet, 
and  above  all  because  persons  of  sedentary  habits  and  those  who  wear 
tight  corsets  do  not  aid  the  expulsion  of  bile  from  the  gall-bladder 
by  active  exercise  of  the  diaphragm  and  abdominal  muscles.  It  is 
possible  also,  and  not  very  infrequent,  for  the  gall-bladder  to  be  infected 
by  way  of  the  systemic  circulation,  through  the  cystic  artery.  This  is 
probably  the  case  in  typhoid  fever,  in  which  disease  the  infecting 
bacillus  usually  can  be  obtained  in  pure  culture  from  the  gall-bladder. 
An  infection  by  way  of  the  common  bile-duct,  ascending  from  the 
duodenum  is  rare. 

If  the  infection  which  reaches  the  gall-bladder  either  through  its 
contained  bile,  or  through  the  blood-stream,  is  very  severe,  the  result- 
ing changes  in  the  gall-bladder  are  acute  in  type.  The  pathology  of 
acute  inflammation  of  the  gall-bladder  (cholecystitis)  corresponds  to 
that  already  discussed  in  connection  with  the  appendix.  The  walls 
of  the  gall-bladder  are  the  seat  of  round-celled  infiltration  (phleg- 
monous inflammation)  and  this  may  lead  to  gangrene  or  to  perforation 
of  the  organ.  If  the  infection  which  reaches  the  gall-bladder  is  very 
mild,  a  slight  catarrhal  inflammation  occurs,  and  the  interaction  of  the 
cholesterin  set  free  in  this  wTay  with  the  salts  contained  in  the  bile 
results  in  the  formation  of  concretions  known  as  gall-stones  or  biliary 
calculi. 

Cholecystitis. — The  pathogenesis  of  this  condition  has  been  described 
It  is  rare  except  as  a  complication  of  gall-stone  disease  (cholelithiasis, 
p.  977).  Swelling  of  the  spiral  folds  of  mucous  membrane  lining  the 
(974) 


CHOLECYSTITIS  975 

cystic  duct  converts  the  gall-bladder  into  a  closed  cavity,  and  the 
virulence  of  the  infection  is  thus  increased.  If  suppuration  occurs 
within  the  gall-bladder  the  condition  is  described  as  empyema  of  the 
gall-bladder.  If  inflammation  spreads  to  the  surrounding  peritoneal 
structures,  pericholecystitis  is  said  to  exist.  Even  if  the  disease  is 
arrested  before  gangrene  or  perforation  occurs  a  return  to  normal 
does  not  ensue;  pericholecystitis  leaves  as  a  legacy  pericholecystic 
adhesions  which  bind  the  gall-bladder  to  the  duodenum,  pylorus,  or 
omentum,  and  which  may  cause  kinking  of  the  bile-ducts;  while 
changes  in  the  wall  of  the  gall-bladder  and  in  the  cystic  duct  impair 
still  more  its  drainage  facilities,  and  stricture  or  occlusion  of  the  cystic 
duct  may  convert  the  gall-bladder  into  a  permanently  closed  cavity 
with  contents  of  very  low  infectious  power,  a  condition  described  as 
hydrops  of  the  gall-bladder.  Chronic  cholecystitis  may  occur  as  a  sequel 
of  an  acute  attack,  or  if  the  infection  is  mild  the  cholecystitis  may  be 
chronic  from  the  beginning.  It  is  very  rare  except  in  cases  of 
cholelithiasis. 


Fig.  977. — Gall-bladder  excised  for  acute  calculous  cholecystitis;  gall-bladder  was 
almost  gangrenous,  and  ruptured  near  fundus  during  removal.  Recovery.  One-half 
natural    size.     Episcopal    Hospital. 

Symptoms  of  Acute  Cholecystitis. — The  patient  usually  is  an  adult 
in  early  middle  life.  The  affection  is  rare  before  thirty  years  of  age, 
and  not  very  frequent  in  those  over  forty  years,  unless  previous  attacks 
have  occurred.  The  attack  usually  begins  with  biliary  colic  (p.  979) 
which  may  be  mild  or  severe.  It  is  a  mistake  to  suppose  that  biliary 
colic  occurs  only  when  gall-stones  are  present;  as  in  the  case  of  the 
appendix,  the  intestine,  and  the  kidney,  the  colic  is  a  sign  of  disordered 
and  violent  peristalsis  in  an  effort  of  the  organ  to  empty  itself  against 
resistance.  The  resistance  may  be  formed  by  a  gall-stone  impacted 
in  the  neck  of  the  gall-bladder  or  in  one  of  the  ducts,  but  it  often 
is  formed  by  inflammatory  occlusion  of  the  cystic  duct,  or  by  an 
exceedingly  viscid  and  tarry  state  of  the  bile  which  is  a  frequent 
condition  in  the  stagnant  gall-bladder.  In  many  cases  of  cholecystitis 
the  pain  is  not  very  severe  at  first,  and  is  felt  in  the  epigastrium,  or 
is  diffused  through  the  abdomen;  soon,  however,  it  settles  to  the  gall- 
bladder region,  to  the  right  of  the  epigastrium  or  in  the  right  hypo- 


976     SURGERY  OF   THE  GALL-BLADDER  AND  BILE-DUCTS 

chondrium.  Sometimes  referred  pain  is  felt  in  the  right  shoulder, 
under  the  scapula,  or  in  the  right  iliac  fossa.  If  the  gall-bladder  lies 
low  in  the  abdomen  the  attack  may  be  confused  with  appendicitis. 
Nausea  and  vomiting  usually  occur,  but  may  be  entirely  absent. 
Muscular  rigidity  and  tenderness  over  the  site  of  the  gall-bladder  are 
constant  and  very  valuable  signs.  The  gall-bladder  becomes  enlarged 
and  usually  can  be  outlined  by  percussion,  and  if  rigidity  and  tender- 
ness are  not  very  great,  it  may  be  palpable  as  a  smooth  rounded  tumor 
beneath  the  costal  margin  continuous  with  the  liver  dulness  and  moving 
in  respiration  unless  fixed  by  adhesions  from  previous  disease.  Jaundice 
does  not  occur  in  uncomplicated  cases  of  cholecystitis;  it  implies 
involvement  of  the  common  or  hepatic  ducts.  There  usually  is  fever, 
but  the  temperature  seldom  is  very  high;  there  is  polynuclear  leuko- 
cytosis. If  there  is  much  constitutional  reaction,  and  if  the  elevation 
of  temperature  continues  for  several  days  and  is  high,  empyema  or 
threatening  gangrene  should  be  suspected.  Perforation  into  the  free 
peritoneal  cavity  is  very  rare  (Fig.  951),  and  is  unusual  even  into 
preformed  pericholecystic  adhesions.  It  may  be  recognized  in  some 
cases  by  sudden  severe  pain,  perhaps  with  symptoms  of  shock,  fall  of 
temperature,  rise  of  pulse  rate,  and  occasionally  by  the  sudden  dis- 
appearance of  a  gall-bladder  tumor  previously  palpable.  Unless  the 
upper  abdomen  is  well  protected  by  adhesions,  spreading  peritonitis 
ensues.  In  the  former  case  a  pericholecystic,  subphrenic  or,  rarely, 
a  perinephric  abscess  results.  Spontaneous  perforation  through  the 
abdominal  wall  {external  biliary  fistula),  or  into  the  gastro-intestinal 
tract  {internal  biliary  fistula)  is  very  rare. 

Diagnosis. — Acute  cholecystitis  must  be  distinguished  from  appen- 
dicitis (p.  900),  gastric  or  duodenal  perforation  (p.  919),  intestinal 
obstruction  (p.  936),  and  acute  pancreatitis  (p.  999).  In  most  cases 
the  correct  diagnosis  is  easy,  owing  to  localization  of  the  signs  and 
symptoms  to  the  gall-bladder  region,  and  the  recognition  of  the 
enlarged  gall-bladder. 

Treatment. — The  patient  should  be  treated  by  rest  in  bed,  in  the 
semi-recumbent  position;  absolute  prohibition  of  food  or  liquid  by  the 
mouth;  hot  or  cold  applications  to  the  upper  right  quadrant  of  the 
abdomen;  and  proctoclysis  of  saline  fluid  or  tap  water.  Most  mild 
cases  of  cholecystitis  will  subside  within  a  day  or  two  under  this 
treatment.  If  anything  is  taken  into  the  stomach  peristalsis  is 
aroused,  and  there  is  danger  of  spreading  the  infection  from  the  gall- 
bladder to  the  bile  ducts  or  to  the  surrounding  peritoneal  structures. 
When  all  acute  symptoms  have  been  absent  for  a  day  or  so,  sodium 
phosphate  in  hot  water  may  be  given  by  mouth,  and  then  feeding 
may  be  cautiously  resumed.  If  the  attack  does  not  subside  promptly, 
suggesting  the  probable  occurrence  of  suppuration  within  the  gall- 
bladder, the  organ  should  be  drained  {cholecystostomy,  p.  985). 

Cholangeitis. — Cholangeitis,  or  inflammation  of  the  bile-ducts,  is 
rare  except  as  a  complication  of  gall-stone  disease,  or  as  a  sequel  of 
catarrhal  gastro-duodenitis  ("catarrhal  jaundice").    In  this  condition 


CHOLANGEITIS  977 

the  duodenal  mucous  membrane  around  the  bile-papilla,  and  that 
in  the  lower  end  of  the  common  duct,  swell  up  and  cause  obstruc- 
tion of  the  biliary  outlet,  resulting  in  the  development  of  jaundice. 
In  many  of  these  cases  it  is  probable  that  swelling  of  the  head  of  the 
pancreas  also  occurs  and  compresses  the  common  bile  duct,  which 
is  known  to  traverse  its  substance  in  two  out  of  three  cases.  If 
the  attack  of  jaundice  occurs  in  the  young,  it  usually  is  due  to  gastro- 
duodenal  catarrh;  jaundice  in  middle  aged  or  old  patients  usually 
is  due  to  gall-stone  disease,  pancreatitis,  or  malignancy.  In  the  latter 
conditions  pain  is  more  marked  (usually  it  is  entirely  absent  in  catarrhal 
jaundice);  the  jaundice  is  of  longer  duration  (usually  it  subsides  in 
a  week  or  ten  days  in  cases  of  gastro-duodenal  catarrh);  it  varies  in 
intensity  unless  there  is  obstruction  by  a  malignant  growth  or  pancre- 
atitis; and  attacks  of  chills  and  fever  are  much  more  common  than 
in  attacks  of  catarrhal  jaundice.  Chronic  catarrhal  cholangeitis  and 
suppurative  cholangeitis  are  very  rare  except  in  connection  with  gall- 
stone disease. 

Treatment. — Cholangeitis  due  to  gastro-duodenal  catarrh  subsides 
promptly  under  appropriate  medical  treatment.  In  other  cases  the 
treatment  is  that  of  the  causative  condition,  and  postoperative  drain- 
age of  the  ducts  should  be  continued  until  the  bile  becomes  and  remains 
free  from  virulent  bacteria. 

Cholelithiasis. — The  formation  of  gall-stones  has  already  been 
alluded  to.  The  chief  predisposing  condition  is  stagnation  of  bile 
in  the  gall-bladder.  As  the  stagnant  gall-bladder  is  more  frequent  in 
women  than  in  men,  so  is  the  occurrence  of  gall-stone  disease.  The 
stagnated  bile  becomes  viscid,  ropy,  and  very  dark  in  color.  It  invites 
infection,  and  when  such  infection  occurs,  in  attenuated  form,  the 
union  of  cholesterin  derived  from  the  mucous  membrane,  with  bile 
salts,  results  in  the  formation  of  concretions  (gall-stones).  Biliary 
sand,  composed  of  minute  cholesterin  crystals,  is  found  not  very 
infrequently  in  such  a  gall-bladder,  which  is  otherwise  apparently 
normal.  This  sand  clings  to  the  mucosa  of  the  gall-bladder  and  can- 
not be  detected  with  the  finger  because  so  fine  and  so  well  covered 
by  mucus;  it  can  be  seen  glistening  on  the  gauze  which  has  wiped  the 
gall-bladder  cavity.  It  is  held  by  AschofT  and  Bacmeister  (1909) 
that  a  concretion  composed  of  pure  cholesterin  may  be  formed  in  the 
gall-bladder  without  the  presence  of  bacterial  infection;  they  teach 
that  this  stone  precedes  the  formation  of  all  other  varieties,  which 
may  be  numerous. 

The  following  varieties  of  gall-stones  may  be  recognized:  (1)  The 
pure  cholesterin  stone  (Figs.  978  and  979)  usually  is  of  fairly  large 
size  and  oval  in  shape;  it  is  soft  when  first  formed  but  becomes  hard 
and  brittle  on  drying;  is  white,  yellowish,  or  brownish  black  on  the 
surface,  but  white  and  crystalline  on  section.  It  is  not  stratified,  but 
is  composed  of  radiating  crystals  around  a  comparatively  soft  center, 
which  in  the  dried  specimen  may  be  hollow.  (2)  Laminated  cholesterin 
stone.  Laminations  indicate  that  secondary  deposits  of  bile  salts  have 
62 


978     SURGERY  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

occurred  around  the  primary  radial  cholesterin  stone.     (3)  The  common 
gall-stones,  or  mixed  cholesterin  calculi,  vary  greatly  in  number  and  size 


Fig.  978. — Radial  cholesterin  stone;  spontaneous  fracture  in  gall-bladder.  Female, 
aged  fifty  years,  with  empyema  of  gall-bladder.  Recovery.  Scale  in  inches.  (See  Fig. 
979.)     Episcopal  Hospital. 

and  usually  are  faceted;  the  surface  color  usually  is  yellowish.     They 
are  all  formed  at  or  about  the  same  time,  and  are  pressed  into  their 


Fig.  979. — Cholesterin  gall-stone,  with  polished  facet  at  each  end.  Same  stone  as 
Fig.  978,  after  fragments  had  been  glued  together.  Scale  in  inches.  Episcopal  Hos- 
pital. 

faceted  shape  while  still  soft  (Fig.  980).     (4)  Mixed  bilirubin-calcium 
stones  are  less  usual,  generally  occur  singly,  or  in  groups  of  three  or 


Fig.  980. — Common  gall-stones,  from  a  gall-bladder  removed  for  acute  calculous 
cholecystitis,  in  a  woman,  aged  thirty-seven  years.  Dyspepsia  for  years,  and  much 
belching  after  meals.  Wakened  one  midnight  by  epigastric  pain ;  two  days  later  enlarged 
gall-bladder  palpated;  admitted  for  operation  on  third  day;  cholecystectomy;  recovery. 
Episcopal  Hospital. 


four,  on  section  show  concentric  layers  of  dark  reddish-brown  material ; 
and  on  drying  usually  contract  with  the  formation  of  fissures.  (5) 
Pure  bilirubin-calcium  stones  also  occur,  as  do  certain  still  rarer  forms. 


CHOLELITHIASIS  979 

Gall-stones  are  the  result  of  previous  disease  in  the  gall-bladder,  and 
may  form  so  silently  that  little  indication  of  their  presence  is  given 
until  some  acute  infection  arises,  causing  acute  calculous  cholecystitis, 
or  cholangeitis.  They  are  formed  in  the  gall-bladder,  not  in  the  liver 
or  bile  ducts,  and  so  long  as  they  remain  in  a  gall-bladder  free  from 
infection  may  produce  no  noteworthy  symptoms.  This  state  is 
described  as  Simple  Cholelithiasis.  But  the  presence  of  the  concre- 
tions predisposes  the  gall-bladder  to  infection,  and  if  one  or  more  of 
the  calculi  wander  from  the  gall-bladder  and  enter  the  cystic  or  the 
common  duct,  very  serious  symptoms  may  arise.  At  operation  these 
ducts  are  found  to  have  been  invaded  by  one  or  more  calculi  in  nearly 
40  per  cent,  of  cases  (Deaver  and  Ashhurst). 

Simple  Cholelithiasis. — This  has  been  defined  above.  The  gall- 
stones have  remained  quiescent  in  the  gall-bladder  since  the  time  of 
their  first  formation,  perhaps  many  years  previously.  The  symp- 
toms are  due  to  a  chronic  catarrhal  cholecystitis,  and  the  pathological 
changes  in  the  gall-bladder  are  not  very  marked.  The  bile  is  thick 
and  tarry,  but  so  long  as  no  acute  infection  occurs  the  patients  are 
not  much  troubled.  But  certain  symptoms  are  present  by  which  the 
disease  may  be  recognized,  and  they  can  be  discovered  by  studying 
carefully  the  history  of  the  case.  These  symptoms  usually  are  con- 
sidered gastric  in  origin,  and  the  patient  attributes  to  "indigestion" 
fleeting  attacks  of  pain,  dull,  boring,  or  grasping  in  character,  which 
occur  in  the  epigastrium,  but  which  are  irregular  in  their  occurrence 
and  are  dependent  on  no  recognized  factor.  Such  symptoms  are 
more  or  less  constantly  present;  there  are  no  free  intervals  such  as 
usually  occur  in  case  of  gastric  or  duodenal  ulcer.  Pylorospasm  may 
occur,  but  vomiting  is  rare,  as  is  acute  pain.  If  slight  pressure  over  the 
gall-bladder  region  relieves  the  discomfort  it  is  probable  that  perichole- 
cystic  adhesions  are  present.  In  cases  of  simple  cholelithiasis  there 
may  be  tenderness  over  the  gall-bladder,  and  various  special  points 
of  tenderness  (corresponding  to  McBurney's  point  in  appendicitis) 
have  been  described,  but  I  have  not  found  them  of  practical  signifi- 
cance. With  the  patient  sitting  and  leaning  forward,  the  surgeon 
may  stand  behind  him,  with  one  hand  hooked  under  each  costal  margin 
at  the  ninth  costal  cartilage.  If  at  the  end  of  deep  inspiration,  which 
forces  the  gall-bladder  against  the  finger  tips,  the  patient  experiences 
a  sudden  severe  pain,  it  is  the  opinion  of  some  that  gall-stones  are 
present.  This  is  known  as  Murphy's  test  for  cholelithiasis;  I  have 
repeatedly  found  it  unreliable.  With  the  patient  recumbent,  the  right 
loin  may  be  supported  with  the  left  hand,  while  with  the  finger  tips 
of  the  right  the  gall-bladder  is  palpated  beneath  the  costal  margin. 
Sometimes  at  the  end  of  deep  inspiration  it  can  be  felt  and  if  diseased 
usually  is  tender  and  painful.  There  is  also  very  commonly  a  tender 
spot  to  the  right  of  the  twelfth  dorsal  vertebra  (Boas's  area). 

Biliary  Colic. — Biliary  colic  usually  has  occurred  once  or  oftener 
before  patients  come  to  the  surgeon  for  operation.  As  stated  already, 
it  may  occur  where  no  calculi  are  present.    In  the  mildest  cases  the 


980     SURGERY  OF   THE  GALL-BLADDER  AND  BILE-DUCTS 


pain  may  be  fleeting,  and  the  patient  may  forget  its  occurrence  unless 
closely  questioned,  especially  as  the  earlier  attacks  of  colic  usually 
cause  pain  in  the  mid-epigastrium  and  not  over  the  gall-bladder.  In 
other  cases,  however,  the  initial  attack  is  severe.  A  man,  believing 
himself  to  be  in  the  enjoyment  of  excellent  health,  except  for  slight 
gastric  symptoms  which  have  never  incommoded  him,  may  suddenly 
have  a  dreadful  cramp  in  his  upper  abdomen;  he  bends  forward  press- 
ing his  hands  or  the  back  of  a  chair  into  his  belly;  breaks  out  in  a 
cold  sweat;  becomes  deathly  pale  and  feels  faint;  is  nauseated;  and 

sometimes  his  distress  is  relieved  by 
vomiting.  Or  he  may  writhe  around 
his  bed,  or  even  on  the  floor  in 
utmost  agony.  When  the  obstruc- 
tion is  relieved  by  the  calculus  fall- 
ing back  into  the  gall-bladder  or  by 
the  cystic  duct  becoming  patulous, 
pain  ceases  instantly.  If  obstruction 
continues  pain  does  not  vanish,  but 
continues  for  hours  or  days,  but  not 
so  intense  as  at  first.  The  pain  now 
shifts  to  the  gall-bladder  region, 
and  may  be  referred  to  the  back 
or  shoulder  through  filaments  of  the 
fourth  cervical  nerve,  from  which 
the  phrenic  is  derived.  When  there 
is  complete  obstruction  of  the  cystic 
duct,  colicky  pain  quickly  disap- 
pears. 

Acute  Calculous  Cholecystitis  is  a 
frequent  occurrence  in  cases  of 
simple  cholelithiasis.  The  symp- 
toms do  not  differ  from  those  of 
non-calculous  cholecystitis  (p.  975), 
and  it  is  largely  on  the  recurrence 
of  symptoms  that  the  diagnosis  of 
gall-stones  is  based. 

Migrated  Gall-stones. — In  many 
cases  of  cholelithiasis  it  is  possible 
to  determine  whether  the  calculi  remain  in  the  gall-bladder  or  have 
escaped  into  the  bile  ducts,  and  especially  whether  or  not  the  common 
duct  is  involved.  As  only  a  few  of  the  calculi  usually  leave  the  gall- 
bladder the  clinical  picture  may  be  somewhat  confusing. 

Stone  in  the  Cystic  Duct. — As  soon  as  a  stone  enters  the  duct,  typical 
gall-stone  colic  results  and  paroxysms  of  pain  recur  until  the  stone 
either  passes  through  the  duct,  returns  to  the  gall-bladder,  or  is  arrested 
permanently  in  the  duct.  If  in  the  latter  case  obstruction  is  com- 
plete, colic  gradually  ceases,  and  usually  the  gall-bladder  becomes 
distended  and  enlarged,  causing  at  first  empyema,  and  later,  if  the 


Fig.  981. — Sites  of  lodgement  of  mi- 
grated biliary  calculi:  in  the  neck  of 
the  gall-bladder;  in  the  cystic  duct;  in 
the  hepatic  duct;  in  the  common  duct 
(supra-duodenal,  retro-duodenal,  or  pan- 
creatic portion),  or  at  the  papilla  of 
Vater. 


MIGRATED  GALL-STONES  981 

infection  becomes  attenuated,  hydrops.  In  many  cases,  however, 
when  a  stone  is  lodged  in  the  cystic  duct,  it  forms  a  diverticulum 
for  itself  and  bile  can  still  enter  and  leave  the  gall-bladder.  Perfor- 
ation in  cases  of  cholelithiasis  occurs  usually  at  or  near  the  origin  of 
the  cystic  duct;  while  in  non-calculous  cholecystitis  it  occurs  oftenest 
at  the  fundus  of  the  gall-bladder. 

Stone  in  the  Common  Duct. — It  is  rare  for  a  stone  to  pass  completely 
through  the  choledochus.  The  larger  stones  are  arrested  in  its  supra- 
duodenal portion,  and  the  smaller  in  its  retroduodenal  or  in  the 
ampulla  of  Vater.  Complete  obstruction,  when  it  occurs,  seldom 
lasts  more  than  a  week  or  ten  days,  the  acute  attack  then  subsiding 
and  perhaps  not  recurring  again  for  weeks  or  months.  Each  attack 
of  colic  is  characterized  by  jaundice,  fever,  and  marked  constitutional 
disturbance.  These  are  absent  in  simple  biliary  colic.  They  are  due 
to  recurrent  attacks  of  cholangeitis,  causing  temporary  complete 
occlusion  of  the  choledochus  with  damming  up  of  bile  and  pus,  very 
seriously  threatening  the  integrity  of  the  liver,  and  frequently  bringing 
the  patient  to  death's  door.  The  calculus  does  not  float  around  free 
in  the  bile-duct,  acting  as  a  ball-valve,  as  described  by  Fenger  (1S96) : 
at  operation  it  usually  is  found  firmly  fixed,  sometimes  in  a  divertic- 
ulum. The  fever  rises  abruptly  to  104°  F.  or  higher,  and  falls  again 
as  rapidly  to  normal  or  subnormal.  It  is  known  as  "Charcot's  inter- 
mittent fever,"  and  Moynihan  described  the  temperature  record  as 
a  "steeple"  chart,  from  its  sudden  variations.  The  jaundice  also 
is  intermittent,  or  at  least  lessens  from  time  to  time,  and  stercobilin 
is  never  very  long  absent  from  the  feces.  Persistence  of  jaundice, 
with  its  accompanying  constitutional  condition,  known  as  cholemia, 
is  a  very  dangerous  feature,  and  the  tendency  to  hemorrhage  becomes 
very  marked,  owing  to  the  prolongation  in  the  clotting  time  of  the  blood. 

When  there  is  calculous  obstruction  of  the  common  duct,  the  gall- 
bladder is  found  to  be  contracted  in  80  per  cent,  of  cases;  and  in  90 
per  cent,  of  cases  where  the  gall-bladder  is  enlarged,  the  obstruction 
is  due  to  causes  other  than  stone,  usually  malignant  disease.  This 
is  known  as  Courvoisier's  Law  (1890).  The  explanation  is  that  the 
gall-bladder  has  been  diseased  so  long  before  the  stones  migrate  into 
the  common  duct,  and  has  become  so  contracted  and  thickened  as  a 
result  of  disease,  that  it  can  no  longer  dilate  under  the  influence  of 
back  pressure. 

Stone  in  the  Hepatic  Duct. — Calculi  are  found  in  the  hepatic  duct 
only  when  they  have  floated  upward  from  the  common  duct,  or  when, 
the  common  duct  being  already  full  of  stones,  others  descending  from 
the  gall-bladder  have  to  pass  into  the  hepaticus.  Gall-stones  (except 
biliary  sand)  are  not  formed  in  the  liver  except  when  the  choledochus 
and  common  hepatic  duct  are  already  filled.  The  symptoms  of  stone 
in  the  hepatic  duct  cannot  be  distinguished  from  those  due  to  common 
duct  calculus. 

Treatment  of  Cholelithiasis. — In  cases  of  simple  cholelithiasis  operative 
treatment  should  be  urged,  unless  any  operation  is  contraindicated 


982     SURGERY  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

by  extreme  age,  or  by  visceral  disease.  There  is  no  medicine  which 
will  cause  the  solution  of  the  stones,  though  charlatans  often  deceive 
patients  by  administering  olive  oil  in  large  quantities  and  telling  them 
that  the  fecal  concretions  so  produced  are  the  biliary  calculi.  But  it 
is  possible  by  strict  medical  treatment,  such  as  diet,  hygiene,  etc.,  to 
keep  the  disease  latent  for  many  years  in  some  cases;  and  most  patients 
who  can  afford  such  a  life  will  be  satisfied  to  adopt  this  procedure 
rather  than  operation.  But  they  should  be  informed  that,  as  Mayo 
writes,  the  danger  of  the  development  of  carcinoma  in  such  a  gall- 
bladder (see  p.  997)  is  five  times  as  great  as  is  the  mortality  following 
operation  for  the  relief  of  simple  gall-stone  disease,  when  performed 
by  a  competent  surgeon.  And  Kehr  says  "the  slight  dangers  of  early 
operation  stand  in  no  sort  of  a  relation  with  the  great  dangers  of  the 
disease  itself;  even  the  latent  cholelithiasis  we  should  always  regard 
with  suspicious  eyes,  for  the  quiet  work  of  gall-stones  is  often  the  most 
destructive.  In  malignancy  and  imidiousness,"  concludes  Kehr,  "no 
disease  of  man  compares  with  choleliihiasis."  If,  after  their  attendant 
has  stated  the  facts  of  the  case,  the  patients  still  will  not  be  operated 
on,  that  is  their  own  concern.  The  mortality  following  operation  in 
these  simple  cases,  in  competent  hands,  is  less  than  5  per  cent. 

The  proper  operation  in  most  cases  of  simple  cholelithiasis  is  removal 
of  the  calculi  and  drainage  of  the  gall-bladder  (cholecystostomy,  p. 
985) ;  if  the  gall-bladder  is  altered  by  disease  it  is  desirable  to  remove  it 
(cholecystectomy,  p.  986).  Recurrence  of  gall-stones  after  cholecyst- 
ostomy is  very  unusual,  and  generally  the  stones  that  are  found  subse- 
quently are  not  newly  formed,  but  were  overlooked  at  the  first  operation. 
The  mortality  of  cholecystectomy  is  slightly  higher  than  that  of  simple 
drainage,  but  in  cases  of  acute  calculous  cholecystitis  it  is  to  be  preferred, 
as  also  in  every  case  where  the  gall-bladder  is  contracted  or  thickened 
or  manifestly  diseased.  Cholecystectomy  is  also  to  be  done  in  cases  of 
obstruction  of  the  cystic  duct  by  a  calculus,  since  stricture,  with  resulting 
hydrops,  is  the  almost  inevitable  result  of  removal  of  such  a  stone.  In 
cases  of  hydrops  and  gangrene  always,  and  in.  most  cases  of  empyema 
or  perforation  removal  of  the  gall-bladder  is  indicated. 

In  cases  of  stone  in  the  common  duct  the  patients  may  come  under 
observation  either  during  an  attack  of  obstruction  with  cholangeitis, 
or  during  a  free  interval.  In  the  latter  contingency  there  is  no  need 
to  postpone  operation,  and  removal  of  the  stone  or  stones  should  be 
undertaken.  In  the  presence  of  acute  complete  obstruction  of  the 
common  duct,  however,  it  is  the  teaching  of  nearly  all  surgeons  that 
operation  should  be  delayed  until  under  medical  treatment  (as  for 
acute  cholecystitis,  p.  976)  complete  obstruction  has  subsided.  Deaver 
and  Ashhurst  contend,  on  the  other  hand,  that  by  waiting  the  patient 
runs  the  risk  of  cholangeitis,  cholemia,  with  the  gravest  form  of  sepsis ; 
not  to  mention  perforation  of  the  common  duct  or  the  formation  of 
almost  inoperable  adhesions,  or  the  indefinite  persistence  of  chronic 
jaundice  with  its  dangerous  hemorrhagic  tendencies.  The  fact  that 
the  mortality  of  operations  during  persistence  of  complete  obstruction 


TYPHOID  CARRIERS  983 

is  very  much  higher  than  that  of  interval  operations  is  not  a  valid 
argument  against  immediate  operation,  since  the  question  is  not 
the  death  rate  from  operation,  but  the  death  rate  from  the  disease. 
Deaver  says  "while  many  times  there  has  been  cause  to  regret  not 
operating  during  the  stage  of  acute  obstruction,  never  yet  has  there 
been  cause  to  regret  prompt  relief  of  the  obstruction  by  operation." 

The  operation  consists  in  removal  of  the  stones  in  the  common  duct 
(by  choledochotomy,  p.  987),  thorough  exploration  of  the  common 
and  hepatic  as  well  as  the  cystic  duct,  and  drainage  of  the  common 
duct  and  the  gall-bladder  by  separate  tubes.  Frequently  the  gall- 
bladder has  to  be  removed. 

Obstruction  of  the  Common  Duct  may  result  from  stricture,  the 
result  of  previous  operative  interference,  or  from  tumor  formation, 
as  well  as  from  lodgement  of  calculi.  If  the  stricture  is  benign  in  nature, 
the  bile  should  be  short-circuited  into  the  intestinal  tract  by  an  anas- 
tomosis between  the  gall-bladder  and  duodenum  or  stomach.  If  the 
gall-bladder  has  been  removed,  and  cholecystenterostomy  is  therefore 
impossible,  an  anastomosis  will  have  to  be  made  between  the  dilated 
duct  above  the  obstruction  and  the  intestine  (choledocho-enterostomy, 
hepatico-enterostomy) .  If  the  obstruction  is  due  to  malignant  disease, 
palliative  operation  may  be  done,  but  has  a  high  mortality.  Radical 
operation  seldom  is  possible.  Carcinoma  of  the  gall-bladder  and  bile- 
ducts  is  considered  at  p.  997. 

In  cases  of  postoperative  external  biliary  fistula  the-  gall-bladder 
should  be  removed,  if  the  common  duct  is  patent;  if  the  gall-bladder 
has  already  been  removed  there  is  almost  certainly  obstruction  of  the 
common  duct.  In  either  case  obstruction  of  the  common  duct  is  to 
be  treated  as  above  indicated.  But  it  should  be  remembered  that  in 
cases  of  pancreatitis  the  fistula  may  close  spontaneously  even  after 
many  months. 

Typhoid  Carriers. — Individuals  are  so  called  who  harbor  in,  and 
discharge  from,  their  bodies  typhoid  bacilli.  Not  all  such  persons 
have  had  typhoid  fever.  The  gall-bladder  is  the  most  frequent  site 
where  the  bacteria  continue  to  live,  but  the  entire  biliary  tract  may  be 
infected;  in  rare  cases  only  the  intestinal  tract  is  at  fault,  or  the  urin- 
ary tract.  Diagnosis  depends  on  the  persistence  and  presence  of  the 
bacilli  in  the  feces  (perhaps  only  after  purgation),  duodenal  contents 
or  in  the  urine.  As  these  people  may  cause  epidemics  of  typhoid 
fever  if  turned  loose  on  the  community,  they  must  either  be  quaran- 
tined or  cured  of  their  infective  qualities.  For  the  latter  purpose 
operation  is  required,  as  no  medicines  are  of  any  value:  the  gall- 
bladder should  be  removed,  and  the  hepatic  duct  drained  until  the 
bile  no  longer  shows  typhoid  bacilli.  If  the  urinary  tract  is  infected, 
removal  of  the  diseased  kidney  is  indicated.  For  the  very  rare  cases 
where  infection  persists  in  the  intestinal  canal,  after  the  bile  has  been 
rendered  sterile,  colostomy  or  ileostomy  with  intestinal  irrigations 
may  be  required. 


984     OPERATIONS  ON   THE  GALL-BLADDER  AND  BILE-DUCTS 

OPERATIONS  ON  THE  GALL  BLADDER  AND  BILE  DUCTS. 

The  deeper  structures  may  be  made  much  more  accessible  by 
placing  a  sand-pillow  (about  10  to  15  cm.  in  thickness)  beneath 
the  patient's  spine,  at  the  level  of  the  liver,  thus  throwing  the  upper 
abdomen  forward,  and  allowing  the  intestines  to  fall  toward  the 
pelvis.  The  head  and  shoulders  should  be  suitably  supported  so  as  to 
facilitate  administration  of  the  anesthetic.  In  very  difficult  cases  the 
foot  of  the  table  may  be  lowered  (reversed  Trendelenburg  posture) 
as  originally  advised  by  Elliot,  of  Boston,  who  introduced  in  1895  the 
position  above  described. 


Bi       Fig.  982. — Mayo  Robson  incision  for  cholecystostoniy.     Episcopal  Hospital. 


The  incision  in  common  use  for  biliary  operations  is  that  known 
as  Mayo  Robson's  (Fig.  982);  in  simple  cases  only  the  longitudinal 
incision  through  the  rectus  muscle  is  necessary.  An  oblique  para- 
median epigastric  incision,  commencing  at  the  ensiform,  dividing  only 
the  anterior  sheath  of  the  rectus  muscle  from  this  point  downward  and 
outward  until*  the  semilunar  line  is  reached  at  or  below  the  level  of 
the  umbilicus,  displacing  the  rectus  muscle  laterally,  and  dividing  its 
posterior  sheath  and  peritoneum  near  the  midline;  gives  as  much  room 
as  Mayo  Robson's  incision,  without  injuring  any  of  the  motor  nerves. 
If,  as  Collins  (1908)  advised,  the  linea  alba  is  cut  transversely  at  the 
upper  limit,  and  the  linea  semilunaris  at  the  lower  limit  of  this  inci- 
sion, ample  exposure  is  secured.  Sprengel's  transverse  incision  (1910) 
which  divides  the  right  rectus  muscle  directly  across  at  whatever 
level  seems  desirable,  and  which  may  be  extended  in  the  same  direction 
if  necessary,  is  gaining  favor.  Before  suturing  any  of  these  incisions, 
the  support  should  be  removed  from  beneath  the  patient's  spine. 


CHOLECYSTOSTOMY  985 

After  the  abdomen  has  been  opened,  the  parts  concerned  in  the 
operation  must  be  well  protected  by  gauze  pads.  One  presses  the 
stomach  out  of  the  way  toward  the  left,  a  second  is  packed  down 
on  the  colon  and  a  third  is  placed  in  the  subhepatic  space  or 
right  kidney  pouch.  Sometimes  another  pad  is  placed  between  the 
right  lobe  of  the  liver  and  the  diaphragm.  In  many  operations  it  is 
possible  to  draw  the  liver,  and  with  it  the  gall-bladder  partly  out 
of  the  wound.  If  the  lower  border  of  the  liver  is  drawn  slightly 
downward  and  then  lifted  upward  into  the  abdominal  incision,  slightly 
rotating  the  organ  so  as  to  turn  its  inferior  surface  toward  the  patient's 
left,  it  fully  exposes  the  gall-bladder  and  brings  the  cystic  and  common 
ducts  very  near  the  surface.  In  this  way  the  cystic  duct  forms  almost 
a  straight  line  with  the  common  duct,  which  is  therefore  more  easily 
found.  An  assistant  should  hold  the  liver  in  this  position  with  the  aid 
of  gauze  sponges.  Too  much  force  must  not  be  used.  I  have  torn 
the  liver  in  trying  to  deliver  it. 

Cholecystotomy  and  Cholecystostomy. — The  former  term  implies 
merely  opening  the  gall-bladder,  while  the  latter  indicates  that  it  is 
left  open  for  the  purpose  of  drainage.  The  terms  often  are  used 
synonymously.  A  gall-bladder  which  needs  to  be  opened  needs  also 
to  be  drained.  The  gall-bladder  is  exposed  and  isolated  by  gauze 
packs.  If  distended  the  contained  fluid  is  removed  by  trocar  and 
cannula,  taking  care  to  prevent  contamination  of  surrounding  struc- 
tures or  the  abdominal  wound.  The  gall-bladder  is  then  pulled  into 
the  wound  and  opened  at  the  fundus  with  scissors,  and  the  finger  is 
introduced  for  exploration. 

Gall-stones  are  removed  with  scoop,  forceps,  or  spoon.  Thick  and 
tarry  bile  is  wiped  out,  and  the  surgeon  makes  sure  that  no  calculi 
remain  in  the  neck  of  the  gall-bladder  or  the  cystic  duct  by  palpation 
with  a  finger  on  the  outside  and  a  sound  in  the  lumen  of  the  duct. 
Unless  the  patient's  condition  forbids,  the  surgeon  should  then  explore 
the  common  duct  and  the  head  of  the  pancreas,  while  the  gall-bladder 
is  temporarily  plugged  with  gauze.  These  manipulations  are  described 
at  p.  987  (Choledochotomy) .  When  it  is  certain  that  no  stones  remain, 
a  drainage  tube  open  on  the  side  as  well  as  at  the  end,  or  cut  in 
fish-tail  fashion,  is  passed  into  the  gall-bladder  for  about  3  cm., 
and  is  stitched  to  the  gall-bladder  with  catgut.  Then  a  purse-string 
suture  of  catgut  is  inserted  in  the  fundus  of  the  gall-bladder  about  2 
cm.  from  the  opening.  The  tube  is  then  pushed  into  the  gall-bladder, 
inverting  its  edges  around  the  tube,  and  the  purse-string  suture 
is  pulled  taut  and  tied.  With  this  valve-like  closure  of  the  opening 
the  biliary  fistula  does  not  remain  open  long  after  the  tube  is  re- 
moved. If  the  gall-bladder  cannot  be  inverted  in  this  manner  the 
opening  should  be  sutured  tightly  around  the  tube,  and  in  such  cases 
or  whenever  there  is  a  possibility  of  leakage  around  the  tube  it  is 
safer  to  insert  also  a  small  cigarette  drain  beside  the  gall-bladder 
(Fig.  983).  The  gauze  pads  are  then  removed  and  the  abdominal 
wound  is  closed  around  the  drainage.  The  tube  in  the  gall-bladder 
remains  until  it  comes  away  of  itself,  which  is  usually  about  the  end 


986     OPERATIONS  ON  THE  GALL-BLADDER  AND  BILE-DUCTS 


of  the  second  week.  The  fistula  in  such  cases  ceases  to  discharge  bile 
very  soon  after  the  tube  is  removed.  When  prolonged  drainage  is 
desired,  as  in  cases  of  cholangitis,  pancreatic  lymphangeitis,  etc., 

the  gall-bladder  should  not  be  in- 
verted around  the  tube,  but  should 
be  closed  tightly  around  it  without 
inversion  of  its  wall;  then  the  gall- 
bladder should  be  sutured  to  the 
parietal  peritoneum,  or  even  to  the 
anterior  sheath  of  the  rectus  mus- 
cle; and  biliary  drainage  should 
persist  for  from  four  to  six  weeks 
at  the  least.  In  some  cases  of  pan- 
creatic disease  many  months  are 
required  before  it  will  be  safe  to 
allow  the  fistula  to  close. 

Cholecystectomy. — After  expos- 
ure and  isolation  of  the  parts  in 
the  usual  way,  the  cystic  duct  is 
identified,  and  the  peritoneum  over- 
lying it  is  incised,  and  is  separated 
from  the  cystic  duct  by  gauze  dis- 
section until  the  common  duct  is 
reached.  The  cystic  duct  is  then 
grasped  with  two  hemostatic  for- 
ceps and  is  divided  between  them. 
The  cystic  artery  and  vein  which  lie  above  and  to  the  inner  side  of  the 
duct  are  then  clamped  with  two  hemostats  and  divided  between. 
The  cystic  vessels  may  be  ligated  now  or  later.  The  gall-bladder 
is  then  enucleated  from  its  attachments  to  the  liver,  leaving  a  peri- 
toneal fold  on  each  side  (Fig.  984).  When  the  gall-bladder  has  been 
removed  these  peritoneal  folds  are  sutured  together;  but  if  there  is 
much  bleeding  from  the  denuded  liver  surface,  or  in  cases  of  marked 
infection,  it  is  safer  to  put  a  cigarette  drain  in  the  bed  of  the  gall- 
bladder and  suture  the  peritoneal  folds  over  it. 

If  on  opening  the  abdomen  the  surgeon  encounters  very  dense 
adhesions,  it  may  not  be  practicable  to  proceed  as  above  indicated. 
In  such  cases  Terrier's  operation  (1905)  is  to  be  preferred:  the  anterior 
margin  of  the  liver  is  identified,  and  the  fundus  of  the  gall-bladder 
found.  The  gall-bladder  is  opened  at  its  fundus  and  its  lower  wall  is 
cut  open  little  by  little  by  snipping  with  fine  scissors.  This  incision 
is  continued  into  and  through  the  cysticus,  right  down  to  the  chole- 
dochus.  The  splitting  of  the  cystic  duct  is  the  most  difficult  part  of 
the  operation,  because  it  cannot  be  distinguished  from  the  outside, 
on  account  of  adhesions,  and  it  is  only  by  following  its  lumen,  as 
one  follows  the  strictured  lumen  of  the  urethra  in  external  perineal 
urethrotomy  without  a  guide,  that  the  choledochus  can  be  reached. 

Before  concluding  the  operation  of  cholecystectomy,  the  common 
and  hepatic  ducts  should  be  sounded,   through  the  stump  of  the 


Fig.  983. — Cholecystectomy :  the  gall- 
bladder tube  is  surrounded  with  gauze 
from  a  cigarette  drain.  (Deaver  and 
Ashhurst.) 


CHOLEDOCHOTOMY 


987 


cystic  duct,  to  make  certain  that  no  calculi  have  been  overlooked.  A 
drainage  tube  is  then  passed  into  the  stump  of  the  cysticus  for  about 
1  cm.,  and  is  stitched  in  position  with  No.  0  chromic  catgut.  The 
subhepatic  space  should  also  be  drained  by  a  tube,  and  these  two 
tubes  must  be  carefully  distinguished  (by  color,  by  insertion  of  two 
safety  pins  instead  of  one,  or  in  some  other  way),  so  that  no  sub- 
sequent confusion  can  arise.  The  abdominal  wound  is  then  closed 
around  the  drainage.  The  tube  to  the  subhepatic  space  may  be 
removed  on  the  second  or  third  day,  but  that  which  drains  the  ducts 
should  be  allowed  to  remain  at  least  for  two  weeks.     If  there  has 


Fig.  984. — Cholecystectomy:  the  cystic  duct  and  the  cystic  vessels  have  been  clamped 
and  ligated,  and  the  gall-bladder  is  being  enucleated  from  its  bed  under  the  liver.  The 
method  of  suturing  the  peritoneal  folds  is  indicated.     (Deaver  and  Ashhurst.) 

been  much  hemorrhage  or  escape  of  bile  into  the  subhepatic  space 
it  is  safer  to  use  a  glass  tube  for  drainage  of  this  region.  This  tube 
is  replaced  by  a  rubber  tube  within  a  few  days,  and  the  subsequent 
treatment  conducted  as  when  a  glass  tube  has  been  used  to  drain  the 
pelvis  (p.  914). 

Choledochotomy  and  Choledochostomy  are  employed  interchange- 
ably as  are  the  corresponding  terms  relating  to  the  gall-bladder,  since 
at  present  almost  every  operation  involving  an  incision  into  the  chole- 
dochus  is  supplemented  by  drainage  of  that  structure.  When  the 
gall-bladder  is  present  it  serves  as  a  guide  to  the  common  duct,  which 


988     OPERATIONS  ON  THE  GALL-BLADDER  AND  BILE-DUCTS 

is  brought  into  the  wound,  when  possible,  by  the  method  noted  at 
p.  985,  after  the  gall-bladder  has  been  opened  and  cleared  of  stones 
as  previously  described.  The  common  duct  often  is  much  dilated 
and  it  may  be  difficult  to  distinguish  it  from  the  portal  vein.  For 
this  purpose  a  hypodermic  needle  may  be  used,  as  advised  by  Terrier 
and  by  Deaver.  The  index  finger  is  passed  into  the  foramen  of  Winslow, 
while  the  thumb  is  placed  on  the  free  border  of  the  gastrohepatic 
omentum  and  the  supraduodenal  portion  of  the  choledochus  is  pal- 
pated. If  a  stone  is  found  it  scarcely  ever  is  possible  to  push  it  back 
through  the  cysticus  into  the  gall-bladder,  but  sometimes  the  scoop 
or  forceps  may  be  passed  down  from  the  gall-bladder  through  the 
cysticus  for  removal  of  the  stone.  In  most  cases,  however,  it  is  neces- 
sary to  incise  the  duct  over  the  stone  to  extract  it.  This  incision  is 
made  in  the  long  axis  of  the  duct  and  of  convenient  length.  If  the 
duct  is  large  enough  the  finger  makes  the  best  probe  to  search  for  other 
stones.  Any  stones  detected  bv  finger  or  scoop  or  sound,  should  be 
pushed  toward  the  opening  in  the  choledochus;  if  impacted  in  the 
retroduodenal  portion  of  the  duct  a  stone  may  be  crushed  between  the 
fingers  or  broken  up  by  the  scoop,  and  the  fragments  extracted  from 
the  incision  in  the  supraduodenal  portion  or  pushed  into  the  duodenum 
through  the  ampulla  of  Vater.  As  a  last  resort  retroduodenal  chole- 
dochotomy  may  be  necessary;  or  if  a  calculus  is  impacted  in  the  lower 
end  of  the  common  duct  very  close  to  the  duodenum,  transduodenal 
choledochotomy  may  be  necessary.  These  operations  are  described 
below. 

When  all  stones  have  been  removed,  the  common  duct  is  drained 
by  passing  a  rubber  tube  large  enough  to  fill  its  lumen  up  toward 
the  hepatic  duct  for  1  to  2  cm.  (Hepaticus  drainage.)  The  tube  is 
fixed  in  the  common  duct,  as  described  in  connection  with  chole- 
cystectomy; and  the  gall-bladder  is  drained  by  a  separate  tube.  (If 
cholecystectomy  is  necessary,  the  stump  of  the  cysticus  should  be 
ligated.)  The  operation  is  concluded  by  drainage  of  the  subhepatic 
space,  as  after  cholecystectomy. 

In  cases  where  the  gall-bladder  is  absent,  choledochotomy  may  be 
a  very  difficult  operation  if  many  adhesions  are  present,  as  there  is 
no  guide  to  its  location.  In  such  cases  the  surgeon  commences  by 
exposing  the  retroduodenal  portion  of  the  choledochus  by  mobilization 
of  the  duodenum  as  described  below.  Or  the  surgeon  may  open  the 
duodenum  antl  identify  the  choledochus  by  retrograde  catheterism 
through  the  ampulla  of  Vater.  I  believe  the  former  method  is  prefer- 
able. 

Retroduodenal  Choledochotomy. — If  an  incision  is  made  through  the 
parietal  peritoneum  on  the  right  of  the  descending  duodenum,  this 
coil  of  intestine  may  be  separated  by  blunt  dissection  from  the  posterior 
abdominal  wall,  and  restored  to  the  condition  it  occupied  in  fetal  life. 
By  turning  the  duodenal  loop  to  the  left  (mobilization  of  the  duodenum, 
Jourdan,  1895)  the  head  of  the  pancreas  and  the  retroduodenal  por- 
tion of  the  common  duct  are  brought  into  view  (Fig.  985),  and  an 
impacted  calculus  may  be  removed  by  direct  incision  (Fig.  986).     As 


CHOLEC  YS  TEN  TEROS  TOM  Y 


989 


in  most  cases  in  which  this  operation  is  necessary  the  supraduodenal 
portion  of  the  choledochus  has  already  been  opened,  this  may  be  used 
for  drainage,  and  the  incision  in  its  retroduodenal  portion  sutured.  It 
is  wise,  however,  to  leave  a  drain  in  the  retroduodenal  space,  for  fear 
of  leakage. 


Fig.  985. — Retroduodenal  choledochot- 
omy:  after  mobilization  of  the  duodenum, 
a  stone  is  exposed  at  the  site  of  obstruc- 
tion to  the  sound.    (Deaver  and  Ashhurst.) 


Fig  986. — Retroduodenal  choledochot- 
omy:  the  choledochus  is  incised  over  the 
impacted  calculus.  (Deaver  and  Ash- 
hurst.) 


Transduodenal  Choledochotomy  (McBurney,  1891)  is  applicable  to  a 
calculus  impacted  in  the  ampulla  of  Vater  or  very  close  to  the  duo- 
denal wall.  The  duodenum  is  opened  through  its  anterior  wall,  and 
the  bile  papilla  identified.  If  a  calculus  is  caught  in  the  ampulla 
it  usually  is  possible  to  extract  it  by  dilating  or  incising  the  papilla. 
If  it  is  impacted  in  the  common  duct  just  outside  the  duodenal  wall, 
it  is  necessary  to  incise  also  the  posterior  wall  of  the  duodenum  over 
the  calculus,  and  then  to  open  the  choledochus  and  remove  the  stone. 
The  opening  in  the  choledochus  is  then  sutured  to  the  incision  in  the 
posterior  duodenal  wall,  to  ensure  adequate  drainage  of  the  chole- 
dochus; this  is  Kocher's  operation  of  dnodeno-choledochostomy  (1895). 
The  incision  in  the  anterior  wall  of  the  duodenum  is  then  sutured  as 
any  intestinal  wound,  and  the  abdominal  incision  is  closed  in  the 
usual  way. 

Cholecystenterostomy. — The  anastomosis  may  be  made  with  the 
duodenum  (cholecysto-duodenostomy)  or  with  the  stomach  (chole- 
cysto-gastrostomy).  A  lateral  anastomosis,  about  an  inch  long,  by 
suture  (p.  886),  is  the  best  method,  but  if  it  is  impossible  to  apply 


000 


SURGERY  OF   THE  LIVER 


rubber-covered  clamps  to  prevent  fecal  extravasation  during  the 
operation,  a  small  sized  Murphy  button  may  be  used  for  the  anasto- 
mosis. 

SURGERY    OF    THE   LIVER. 

Anomalies  of  Shape  and  Position. — Except  in  rare  cases  of  con- 
genital, diaphragmatic,  or  umbilical  hernia  the  position  of  the  liver 
seldom  is  altered  unless  hepatoptosis  (falling  of  the  liver)  exists  in  con- 
nection with  visceroptosis  (p.  053).  Apart  from  rather  vague  pains 
hepatoptosis  produces  no  characteristic  symptoms  and  the  diagnosis 
must  be  made  by  recognition  of  the  liver  in  its  abnormal  position. 
Usually  it  descends  somewhat  toward  the  median  line,  and  is  recognized 
as  a  large  tumor  to  the  right  of  the  umbilicus  of  the  size  and  con- 
sistency of  the  liver;  often  a  notch  can  be  felt.  When  displaced 
there  is  resonance  over  the  normal  site  of  the  liver  dulness,  and 
pulmonary  resonance  and  intestinal  tympany  may  merge.  It  is 
distinguished  from  a  movable  or  enlarged  kidney  by  the  absence  of 
urinary  symptoms,  by  the  fact  that  the  liver  moves  in  respiration, 
while  the  kidney  does  not,  and  that  it  lies  in  front  of  the  colon,  not 
behind  it. 

Treatment. — Treatment  should  consist  in  reposition  of  the  liver, 
when  this  is  possible,  with  the  patient  recumbent,  and  the  applica- 
tion of  an  abdominal  belt  as  in  cases  of  pendulous  abdomen  (Fig. 
063).  If  palliative  treatment  proves  ineffective,  the  abdomen  may 
be  opened  and  the  anterior  margin  of  the  liver  stitched  to  the  costal 
border,  with  mattress  sutures  of  heavy  chromic  catgut. 

Changes  in  the  Shape  of  the  Liver  usually  are  acquired,  and  are  of  two 
main  varieties.    In  one,  the  so-called  corset  liver  (Fig.  087),  the  plastic 

liver  has  become  indented 
by  compression  through  the 
costal  margin.  This  tends  to 
distort  the  cystic  duct,  caus- 
ing stagnation  of  bile,  with 
its  consequences  already  dis- 
cussed (p.  077).  In  the  other 
form  the  anterior  margin  of 
the  liver  is  drawn  down  in  a 
tongue  -  shaped  protrusion, 
known  as  linguiform  or  Riedel's 
lobe  (1888).  Usually  disease 
of  the  biliary  tract  exists  and 
has  produced  the  deformity 
by  gradual  traction  from  ad- 
hesions or  the  weight  of  an 
enlarged  gall-bladder.  Treat- 
ment involves  operative  cure 
of  the  biliary  lesion,  after 
which  the  enlarged  lobe  usu- 
ally shrinks  (Terrier) ;  in  rare  instances  amputation  of  the  lobe  may 
be  desirable. 


Fig.  987. — Corset  liver,  from  a  patient  aged 
fifty-seven  years.  Death  from  perforation  of  a 
malignant  ulcer  of  the  stomach.  (See  Fig.  932.) 
Episcopal  Hospital.    (Deaver  and  Ashhurst.) 


SUPPURATIVE  HEPATITIS  991 

Suppurative  Hepatitis. — There  are  three  main  varieties  of  suppura- 
tion which  occur  in  the  liver:  (1)  Abscess  the  result  of  trauma;  (2) 
pyemic  or  embolic  abscess;  and  (3)  tropical  or  amebic  abscess. 

1.  Traumatic  Abscess  is  rare;  it  may  occur  as  the  result  of  a  pene- 
trating wound,  or  from  secondary  infection  (through  the  blood  or 
bile)  of  a  hematoma  which  has  resulted  from  subcapsular  rupture 
(p.  893);  usually  is  single  and  may  be  of  large  size.  The  diagnosis 
depends  on  the  history  of  the  case,  and  development  of  symp- 
toms of  pus  formation;  and  the  treatment  is  the  same  as  for  tropical 
abscess. 

2.  Pyemic  or  Embolic  Abscess,  when  of  surgical  interest,  almost 
invariably  is  the  result  of  infection  through  the  portal  circulation,  and 
is  termed  suppurative  pylephlebitis.  Especially  frequent  as  causes 
are  appendicitis  and  typhoid  fever,  but  any  infection  in  the  distribu- 
tion of  the  portal  vein  may  be  the  cause;  and  cases  of  suppurative 
cholangeitis  involving  the  finer  intrahepatic  bile-ducts  often  cannot 
be  distinguished  either  during  life  or  at  autopsy  from  cases  of  suppu- 
rative hepatitis  caused  by  hematogenous  infection.  When  occurring 
from  appendicitis  or  other  acute  infection  the  symptoms  (pain,  high 
but  irregular  fever,  chills,  sweats,  tenderness,  and  enlargement  of  the 
liver,  sometimes  jaundice)  usually  develop  within  a  week  or  two  of 
the  primary  affection.  In  such  cases  the  liver  is  riddled  with  abscesses 
of  various  size,  and  operative  treatment  is  out  of  the  question.  Every 
such  case  is  fatal.  When  resulting  from  typhoid  fever,  however,  and, 
according  to  Quenu  and  Mathieu  (1911),  occasionally  as  the  result 
of  appendicitis,  the  symptoms  do  not  appear  until  convalescence  is 
established.  The  average  fever-free  interval  in  typhoid  fever,  according 
to  Melchior  (1910),  is  fourteen  days.  Such  cases  resemble  somewhat 
amebic  abscess,  and  treatment  is  the  same. 

3.  Tropical  or  Amebic  Abscess  takes  its  name  from  its  occurrence 
especially  in  the  tropics,  and  as  the  result  of  infection  with  the  Amoeba 
coli.  The  patient  usually  gives  a  history  of  residence  in  tropical  or 
semi-tropical  climes,  and  almost  always  has  suffered  from  dysentery; 
but  as  the  symptoms  of  amebic  colitis  sometimes  are  very  insignificant 
(p.  950)  too  much  faith  should  not  be  put  in  the  patient's  history. 
The  hepatic  abscess,  which  usually  is  single  (in  60  per  cent,  of  cases) 
and  of  large  size,  may  not  develop  or  at  least  may  not  begin  to  produce 
symptoms  until  man}'  years  after  the  occurrence  of  the  primary 
infection.  The  ameba  is  transported  to  the  liver  through  the  portal 
circulation,  and  the  destructive  process  begins  in  the  hepatic  cells. 
The  abscess  usually  is  in  the  right  lobe  of  the  liver,  but  even  when 
the  abscess  is  very  large  the  shape  of  the  liver  may  not  be  noticeably 
altered.  The  abscess  develops  silently,  like  a  cold  abscess,  and  it 
often  produces  no  symptoms  until  secondary  infection  has  occurred. 
When  uninfected  by  pyogenic  organisms  the  contents  are  reddish 
brown  in  color  and  vary  in  consistence  from  fluid  to  gelatinous. 
Amebae  often  cannot  be  found  except  in  scrapings  from  the  wall  of  the 
abscess,  or  after  it  has  been  discharging  for  several  days. 


992 


SURGERY  OF   THE  LIVER 


Symjrtoms. — In  one-third  of  the  cases,  according  to  Rouis,  there 
are  no  symptoms  noticed  by  the  patient  until  rupture  occurs,  usually 
into  the  lungs,  pleura,  or  peritoneal  cavity.  When  symptoms  exist, 
they  may  not  be  referred  to  the  liver  for  months  after  malaise,  lassitude, 
and  increasing  weakness  are  noted.  Jaundice  is  rare.  When  local 
symptoms  are  noted  they  frequently  are  referred  to  the  base  of  the 
right  lung  or  the  pleura.  Fever  is  another  valuable  sign,  though 
the  temperature  may  not  be  high  except  in  the  evening;  in  malaria 
the  temperature  usually  rises  in  the  daytime.  Enlargement  of  the 
liver,  and  pain  (local  and  referred  to  the  right  shoulder)  may  not 
occur  until  late.  Diagnosis  is  aided  by  purging  the  patients  with 
salines  and  searching  the  stools  for  amebse,  which  usually  can  be  found 
in  the  third  or  fourth  watery  stool.  A  high  leukocyte  count  in  the 
afternoon  is  regarded  as  an  indication  of  the  presence  of  secondary 
infection.  The  most  common  mistakes  in  diagnosis  are  (1)  failure 
to  recognize  the  presence  of  disease  of  any  description;  (2)  misinter- 
pretation of  the  significance  and  nature  of  basic  pneumonia;  (3) 
attributing  the  fever  to  malaria;  and  (4)  mistaking  other  diseases  for 
abscess  of  the  liver,  and  vice  versa  (Manson,  1904).  In  tropical 
abscess  the  spleen  is  not  enlarged. 


Fig.  988. — Transpleural  operation  for  abscess  of  the  liver:  a  portion  of  rib  has  been 
excised,  subperiosteally;  and  the  diaphragm  is  being  sutured  to  the  tissues  or  the  costo- 
phrenic  sinus.     (Deaver  and  Ashhurst.) 

Treatment. — Treatment  involves  drainage  of  the  abscess.  At  the 
same  time  proper  treatment  of  the  colitis  (p.  950)  must  be  instituted 
and  emetin  hydrochloride  (0.04  to  0.08  gram  daily)  should  be  given. 
The  operation  of  hepatotomy  for  drainage  of  a  liver  abscess  resembles 
that  for  subphrenic  abscess  (p.  865).  If  the  abscess  cannot  be  localized 
by  the  physical  signs,  laparotomy  should  be  done  and  its  position 
determined.  No  attempt  should  be  made  to  localize  the  abscess  by 
aspiration,  except  after  the  liver  has  been  exposed  to  view.  If  the 
abscess  is  found  to  be  near  the  convex  surface  of  the  liver  or  if  this 
fact  can  be  determined  without  opening  the  abdomen,  the  abscess 
should  be  drained  by  the  transpleural  route  (Knowsley  Thornton, 
1885)  as  in  the  operation  for  subphrenic  abscess:  Excise  (subperi- 
osteally) 10  cm.  of  the  eighth,  ninth  or  tenth  rib  in  the  mid-axillary 


ECHINOCOCCUS  CYST 


993 


line;  then  suture  the  diaphragm  to  the  tissues  of  the  costo-phrenic 
sinus  (deep  layer  of  costal  periosteum,  both  layers  of  pleura),  without 
opening  the  pleura,  by  three  or  four  interrupted  sutures  of  chromic 
catgut  (Fig.  9S8).  Then  make  an  incision  along  the  upper  border  of 
the  next  lower  rib,  through  all  structures,  diaphragm  included,  until 
the  liver  is  exposed.  In  acute  cases  the  liver  is  bluish,  soft  and  pulpy, 
and  may  bulge  into  the  wound.  Adhesions  usually  shut  off  the  peri- 
toneal cavity,  but  it  is  well  to  isolate  the  parts  with  gauze.  Where 
these  adhesions  are  the  densest,  usually  the  abscess  is  found.  It  is 
opened  by  a  grooved  director,  and  the  tract  enlarged  by  dressing 
forceps  followed  by  the  finger.  It  is  drained  by  a  double  tube  of  rubber, 
and  not  until  four  or  five  days  at  least  have  elapsed  should  irrigation 
be  employed.    The  sinus  may  take  many  weeks  to  close. 


Fig.  989. — Hepatic  abscess  exposed  by  flap  method.  Appendicostomy  for  accom- 
panying colitis.  Catheter  in  the  appendix.  Recovery.  (Dr.  C.  H.  Frazier's  case.) 
Episcopal  Hospital. 

Echinococcus  Cyst. — Hydatid  cyst  is  the  result  of  infection  by  the 
Tenia  echinococcus,  a  parasite  found  in  the  intestinal  tract  of  dogs, 
sheep,  and  other  animals.  The  ova  enter  the  intestinal  tract  of  man 
with  food  or  drink,  or  possibly  as  the  result  of  handling  or  being  licked 
by  an  animal  infested  by  the  parasite.  The  capsule  is  digested  in  the 
intestinal  tract  of  the  patient,  and  the  embryo  is  liberated.  It  bores 
into  the  intestinal  wall,  and  in  most  cases  is  carried  by  the  portal 
system  to  the  liver.  Hydatid  cysts  of  other  organs  or  tissues  are  rare 
and  often  secondary  to  a  primary  growth  in  the  liver.  After  the  para- 
site (in  larval  state)  reaches  the  liver,  it  loses  its  hooklets  and  enters 
the  immature  or  cysticercus  stage.  Inflammatory  changes  cause  a 
connective  tissue  encapsulation,  so  that  the  cyst  wall  consists  of  two 
layers;  an  outer  laminated  layer  or  capsule,  and  an  inner  granular 
or  germinal  layer.  The  contents  are  clear,  colorless  fluid,  unless  sec- 
ondary infection  occurs,  when  the  fluid  is  purulent;  sometimes  it  is 
bloody  or  bile-stained.  Hydatid  fluid  contains  a  poisonous  ptomain, 
63 


994 


si  i:<;ei;y  of  the  LIVER 


which  may  cause  convulsions,  rapidity  of  the  pulse  and  respirations, 
dilated  pupils  and  collapse.  Unless  the  parasite  dies  daughter  cysts 
develop  within  the  original  parent  cyst.  The  heads  or  scolices  of  the 
parasites  cling  to  the  germinal  layer  in  pedunculated  vesicles  known 
as  brood  capsules.  These  are  similar  to  the  primary  cyst.  The 
scolices  may  become  detached  and  lie  free  in  the  brood  capsule,  or  if 
this  ruptures  they  may  float  free  in  the  parent  cyst.  Degeneration, 
calcification,  and  death  of  the  parasites  may  occur.  Hydatid  cysts 
usually  occur  in  the  right  lobe  of  the  liver  and  in  90  per  cent,  of 
cases  the  cyst  is  solitary. 

Symptoms. — The  clinical  course  of  the  disease  much  resembles  that 
of  tropical  abscess  of  the  liver.  So  long  as  secondary  infection  is 
absent,  and  until  the  cyst  grows  so  large  as  to  project  from  the  surface 
of  the  liver,  symptoms  are  inconspicuous.  The  average  duration  of 
the  disease  before  treatment  is  sought  is  from  five  to  seven  years. 
Attacks  of  urticaria  are  not  uncommon.  There  is  danger  of  rupture 
(spontaneous  or  from  trauma),  into  the  bile  passages,  the  peritoneal 
cavity,  the  gastro-intestinal  tract,  or  the  thorax;  as  well  as  from 
secondary  infection. 

Diagnosis. — The  diagnosis  can  be  made  only  when  a  palpable  cystic 
enlargement  of  the  liver  is  detected.  The  condition  must  be  dis- 
tinguished from  carcinoma  of  the  liver,  which  is  a  solid  growth,  and 
usually  secondary  to  a  tumor  elsewhere;  from  tropical  abscess  (p.  991); 
from  empyema  thoracis  and  subphrenic  abscess;  and  from  gummatous 
growths  (syphilitic)  of  the  liver,  which  are  much  more  common  in  this 
country  than  hydatid  cysts. 

Treatment. — There  is  no  cure  without  operation.  Most  cysts  grow 
downward  and  are  best  exposed  by  laparotomy.     The  best  plan  is 

that  of  Quenu;  after  exposure  of  the 
cyst  its  contents  are  aspirated  by  means 
of  a  very  fine  trocar  and  cannula.  It  is 
well  to  insert  the  trocar  through  the 
rubber  tube  used  to  drain  the  fluid  from 
the  cannula  (Fig.  990),  as  in  this  way  no 
danger  of  leakage  occurs.  Then  a  solution 
of  formalin  (1  per  cent.)  is  allowed  to  run 
into  the  cyst  cavity  and  to  distend  it. 
This  is  permitted  to  remain  for  five 
minutes  so  as  to  sterilize  its  contents. 
It  was  demonstrated  by  Deve  (1901) 
that  each  of  the  parasitic  elements  is 
capable  of  reproducing  the  primary 
lesion,  and  Quenu  found  (1902)  that 
formolization  as  above  described  steril- 
ized the  contents  of  the  cyst  absolutely.  The  cyst  is  then  emptied,  its 
wall  is  incised,  and  the  germinal  membrane  is  removed.  Then  the  cyst 
may  be  obliterated  by  sutures,  without  drainage,  but  it  should  be 
attached  to  the  abdominal  wound  so  that  an  intracystic  effusion  of  bile 


Fig.  990. — Quenu's  method  of 
formolization  of  hydatid  cysts  of 
the  liver. 


CIRRHOSIS  OF  THE  LIVER  995 

or  blood  can  be  evacuated  easily  should  either  complication  occur  later. 
If  the  old  plan  of  marsupialization  (opening,  packing  with  gauze,  and 
suturing  to  the  abdominal  wound)  is  employed  without  formoliza- 
tion,  the  condition  is  analogous  to  that  of  a  cold  abscess  opened  and 
drained — secondary  infection  is  almost  unavoidable,  biliary  effusion 
is  frequent,  and  the  sinus  takes  very  long  (months)  to  close. 

Cirrhosis  of  the  Liver. — Pathologists  distinguish  between  portal  cir- 
rhosis, in  which  the  cause  is  transmitted  by  the  portal  circulation,  and 
the  obtrusive  symptoms  are  those  of  portal  obstruction;  and  biliary 
cirrhosis  in  which  the  essential  lesion  is  a  radicular  cholangeitis,  and 
the  conspicuous  clinical  feature  is  jaundice  (A.  O.  J.  Kelly,  1908). 
The  latter  is  not  amenable  to  surgical  treatment,  though  proper 
operative  treatment  of  diseases  of  the  gall-bladder  and  bile-products 
may  often  prevent  its  development;  and  in  the  former  surgery  is 
able  only  to  modify  or  lessen  the  distressing  symptoms,  without  in 
any  way  bringing  about  a  cure  of  the  underlying  disease. 

The  main  symptoms  of  portal  cirrhosis  of  the  liver  are  (1)  gastro- 
intestinal hemorrhages,  from  obstruction  of  the  portal  vein,  and  (2) 
ascites  from  peritoneal  changes  which  accompany  the  disease.  Pure 
portal  obstruction  is  said  not  to  produce  ascites,  which  it  is  believed 
is  caused  almost  solely  by  changes  in  the  endothelium  of  the  peri- 
toneum; it  is  in  the  nature  of  a  chronic  serositis,  probably  due  to  the 
toxemia  of  disordered  hepatic  function.  Cases  of  portal  cirrhosis 
sometimes  are  complicated  by  tuberculosis  of  the  peritoneum,  or  by 
a  chronic  polyserositis  associated  with  cardiac  disease;  and  in  such 
cases  it  may  not  be  the  hepatic  toxemia,  but  the  complicating  disease 
which  is  responsible  for  the  peritoneal  effusion.  Most  of  the  operative 
methods  proposed  for  the  relief  of  ascites  are  based  on  the  idea  that 
this  occurs  as  a  direct  transudate  from  the  portal  system.  Such  is 
not  the  case,  and  a  rational  operation  must  seek  to  alter  the  nutrition 
of  the  peritoneal  endothelium;  operations  which  seek  to  establish 
a  collateral  circulation  for  the  obstructed  portal  system  are  rational 
only  when  gastro-intestinal  hemorrhages  are  present  or  threaten. 

Paracentesis. — The  ascitic  fluid  may  be  removed  by  repeated  tap- 
pings, and  in  rare  instances  the  fluid  finally  ceases  to  re-accumulate. 
The  trocar  and  cannula  should  be  thrust  into  the  abdomen  in  the  mid- 
line between  umbilicus  and  pubes,  after  it  has  been  ascertained  that 
the  bladder  is  empty.  No  anesthetic  is  necessary,  though  in  nervous 
patients  or  when  the  abdominal  wall  is  thick,  a  local  anesthetic  may  be 
used.  The  patient  should  be  in  the  semi-recumbent  position,  and  as 
the  fluid  is  evacuated  concentric  pressure  should  be  made  on  the  abdo- 
men by  means  of  a  many-tailed  bandage,  so  as  to  prevent  syncope 
by  the  sudden  relief  of  pressure  on  the  large  abdominal  bloodvessels. 
If  the  amount  of  fluid  is  very  great,  it  is  best  not  to  remove  all  of  it 
at  once.  The  puncture  is  sealed  with  collodion,  and  the  abdomen 
kept  tightly  bandaged,  in  an  effort  to  prevent  re-accumulation. 

Laparotomy  with  gauze  abrasion  of  the  serous  surfaces  of  the  liver, 
spleen,  and  diaphragm,  in  an  effort  to  alter  their  nutrition,  and  check 


990  SURGERY  OF   THE  LIVER 

the  formation  of  the  ascitic  fluid,  which  is  simultaneously  evacuated, 
is  a  more  effectual  method  of  treatment,  and  much  of  the  good  attrib- 
uted to  epiplopexy  (see  below)  is  no  doubt  due  to  these  steps  which 
form  an  integral  part  of  that  operation. 

Epiplopexy,  introduced  by  Talma  (1889)  and  Morison  (1894),  con- 
sists in  suturing  the  omentum  to  the  parietal  peritoneum  on  both 
sides  of  the  abdominal  incision,  or  between  the  peritoneum  and  the 
posterior  sheath  of  the  rectus  muscle,  in  the  effort  to  establish  a 
collateral  circulation.  As  already  noted,  abrasion  of  the  serous 
surfaces  of  the  liver,  spleen,  diaphragm,  and  of  the  parietal  peritoneum 
forms  an  integral  part  of  this  operation,  the  idea  being  that  a  collateral 
circulation  will  be  established  in  the  adhesions  thus  produced.  The 
surest  maimer  of  establishing  a  collateral  circulation  for  portal  obstruc- 
tion is  to  make  an  anastomosis  between  the  portal  vein  and  vena 
cava  (Eck's  fistula);  this  was  done  by  Vidal  (1903)  in  a  patient  almost 
exsanguinated  by  gastro-intestinal  hemorrhages;  but  though  these 
were  cured,  the  ascites  was  not,  and  death  ensued  four  months  later 
from  acute  general  infection,  evidently  enterogenous;  the  portal 
blood-stream  had  been  short-circuited  and  the  liver  was  no  longer 
interposed  against  the  hordes  of  microbes  constantly  absorbed  from  the 
bowels. 

After  epiplopexy  the  abdomen  is  not  drained,  though  this  formerly 
was  considered  essential.  Symptomatic  relief  has  been  secured  in  from 
one-third  to  one-half  the  cases. 

Splenectomy  is  proposed  by  Mayo  (1918)  as  a  means  of  relieving  the 
overburdened  liver  and  affording  it  an  opportunity  to  recuperate. 
Removal  of  the  spleen  may  not  only  lessen  the  liver's  work  by  cutting 
off  much  of  the  portal  circulation,  but  may  at  the  same  time  eliminate 
a  constant  stream  of  bacteria  or  their  toxins  strained  out  of  the  general 
circulation  by  the  spleen  and  passed  on  to  the  liver  for  destruction. 

Tumors  of  the  Liver,  Gall-bladder,  and  Bile  Ducts. — Benign  tumors 
are  very  rare  and  have  little  surgical  interest. 

Carcinoma  of  the  Liver  may  be  primary,  but  in  almost  all  cases  is 
secondary  to  a  growth  in  the  distribution  of  the  portal  system.  The 
usual  type,  whether  primary  or  secondary,  is  nodular  or  multiple 
carcinoma.  If  this  is  a  primary  growth  most  of  the  nodules  are  metas- 
tases from  one  original  focus  which  usually  is  in  or  near  the  gall- 
bladder (Beadles,  1896);  while  in  secondary  carcinoma  the  nodules 
are  scattered  all  over  the  liyer  uniformly,  and  not  massed  about  the 
fossa  of  the  gall-bladder.  The  nodules  are  whitish,  gray,  or  yellowish 
masses,  from  the  size  of  a  pinhead  to  that  of  an  orange,  but  seldom 
larger  than  a  walnut.  They  stand  out  from  the  surface  of  the  liver, 
frequently  cause  perihepatitis  with  resulting  adhesions ;  and  when  large 
often  become  umbilicated  as  the  result  of  interstitial  hemorrhages. 
If  the  growth  is  primary,  gall-stones  usually  are  present. 

Symptoms  are  not  characteristic,  and  the  diagnosis  rarely  is  made 
until  enlargement  of  the  liver,  with  palpable  nodules,  and  the  develop- 
ment of  ascites  and  sometimes  of  jaundice,  indicate  that  the  disease 


TUMORS  OF  LIVER,  GALL-BLADDER,  AND  BILE-DUCTS     997 

has  passed  the  operable  stage.  The  symptoms  of  the  secondary 
growth  in  the  liver  frequently  overshadow  those  due  to  the  primary 
focus  in  pancreas,  stomach  or  intestinal  tract,  and  even  at  autopsy 
it  may  be  difficult  to  find  the  primary  growth. 

Treatment  in  almost  all  cases  must  be  palliative;  very  occasionally 
a  primary  growth  may  be  excised,  but  in  most  patients  the  prognosis 
is  hopeless,  and  death  ensues  in  from  five  to  seven  months  after  recog- 
nition of  the  condition. 

Sarcoma  of  the  Liver  almost  always  is  secondary,  usually  to  a  growth 
in  the  eye  or  the  soft  tissues  of  the  limbs;  but  many  years  occasionally 
elapse  between  removal  of  the  primary  tumor  and  evidence  of  hepatic 
involvement. 

Carcinoma  of  the  Gall-bladder  and  Bile-ducts  is  much  more  common 
than  carcinoma  of  the  liver.  Secondary  carcinoma  is  rare  and  of  little 
surgical  importance. 

Primary  Carcinoma  of  the  Gall-bladder  is  found  in  about  2  per  cent, 
of  specimens  removed  by  cholecystectomy;  and  almost  invariably 
gall-stones  are  present  and  are  regarded  as  the  predisposing  cause. 
The  growth  begins  at  the  fundus  or  near  the  neck  of  the  gall-bladder, 
and  extension  occurs  to  the  liver.  The  early  symptoms  are  those  of 
cholelithiasis;  later  a  hard  nodular  tumor  of  the  gall-bladder  is  rec- 
ognized, but  by  this  time  hepatic  involvement  frequently  renders  the 
case  inoperable.  The  most  favorable  cases  are  those  where  a  thick- 
walled  gall-bladder  removed  at  operation  is  discovered  to  be  the  seat 
of  carcinoma  only  when  microscopically  examined.  Such  patients 
may  survive  several  years,  whereas  those  in  whom  the  correct 
diagnosis  is  made  before  or  during  operation  usually  die  within  a 
year. 

Treatment  consists  in  extirpation  of  the  growth  whenever  possible. 
This  always  should  include  excision  of  the  entire  cystic  duct  with  the 
gall-bladder  and  may  necessitate  removal  of  the  adjoining  liver  tissue 
also.  Methods  of  suture  of  the  liver  have  already  been  considered 
(p.  895). 

Primary  Carcinoma  of  the  Bile  Ducts  presents  much  the  same  symp- 
toms as  carcinoma  of  the  head  of  the  pancreas,  notably  obstructive 
jaundice,  of  slow  or  sudden  but  almost  always  painless  onset,  never 
remitting  but  gradually  deepening  to  a  bronze  or  almost  black  hue. 
If  the  growth  is  in  the  choledochus,  the  gall-bladder  becomes  dis- 
tended and  enlarged,  and  is  palpable  through  the  abdominal  wall  in 
half  of  the  cases.  If  the  growth  is  in  the  hepaticus  (which  is  rare), 
no  enlargement  of  the  gall-bladder  occurs.  Disturbance  of  the 
pancreatic  functions  indicates  obstruction  at  the  papilla  of  Vater. 

Treatment. — Exploratory  operation  is  proper  in  all  but  manifestly 
hopeless  cases.  If  a  radical  operation  cannot  be  done,  the  gall- 
bladder may  be  drained  into  the  duodenum  or  stomach  (p.  989); 
but  palliative  operations  in  these  conditions  have  a  high  mortality 
(hemorrhage  from  cholemia)  and  do  not  prolong  the  patient's  life 
though  they  may  promote  his  comfort.     If  complete  extirpation  can  be 


998  SURGERY  OF   THE   PANCREAS 

dour,  the  drainage  of  bile  into  the  intestine  must  be  restored  by  some 
form  of  biliary-intestinal  anastomosis  (p.  983).  Retroduodenal  resec- 
tion of  the  choledochus   (Oppenheimer   L912)   gives    an    immediate 

mortality  of  50  per  cent.  Occasionally  a  growth  at  the  papilla  of 
Vater  can  be  excised  by  a  transduodenal  operation  (Czerny,  L901). 
The  immediate  mortality  of  this  operation,  according  to  Oppenheimer, 
is  33  per  cent.  The  most  radical  operation  of  all  for  growths  at  the 
lower  end  of  the  choledochus  resembles  that  of  cephalic  pancreatectomy 
(p.  1005). 

SURGERY   OF    THE  PANCREAS. 

Infections  of  the  Pancreas. — Theoretically  infection  may  reach  the 
pancreas,  as  it  may  any  other  organ,  (1)  through  the  blood-stream ; 
(2)  along  its  excretory  ducts;  (3)  through  its  lymphatics;  or  (4)  by 
contiguity,  from  neighboring  structures. 

1.  Infection  through  the  blood  is  comparatively  rare.  The  pancreas 
is  seldom  affected  in  pyemia;  but  the  occurrence  of  pancreatitis  as  a 
complication  of  acute  parotitis  (mumps),  though  unusual,  is  well  recog- 
nized (Deaver  and  Ashhurst  tabulated  01  cases  in  1913);  and  a  few 
cases  of  involvement  of  the  pancreas  have  been  reported  in  cases  of 
scarlatina,  influenza,  and  other  acute  infections.  In  chronic  interaci- 
nar  pancreatitis,  also,  which  is  a  frecment  accompaniment  of  arterio- 
sclerosis and  which  usually  results  in  diabetes,  the  causative  agent 
is  conveyed  to  the  pancreas  in  the  blood-stream;  and  it  is  probable, 
as  pointed  out  below,  that  acute  pancreatitis  is  the  result  of  some 
toxin  which  exerts  its  action  first  on  the  endothelial  lining  of  the 
bloodvessels. 

2.  Infection  through  the  ducts  has  been  produced  experimentally 
by  injection  of  bile,  gastric  juice,  and  other  irritants,  resulting  in 
acute  inflammation.  Opie  (1901)  recorded  a  case  in  which  a  small 
gall-stone  blocked  the  orifice  of  the  ampulla  of  Vater  and  allowed 
retrojection  of  bile  into  the  pancreatic  duct,  and  Archibald  (1910) 
maintains  that  spasm  of  the  sphincter  of  Oddi  is  a  frequent  cause  of 
this  occurrence,  and  that  most  cases  of  pancreatitis  may  be  thus 
explained. 

3.  Infection  through  the  Lymphatics. — The  lymph  nodes  around 
the  head  of  the  pancreas  drain  the  lymph  from  the  gall-bladder  and 
bile-ducts,  as  well  as  (more  or  less  directly)  from  the  pylorus,  the 
appendix,  and  other  common  sites  of  intra-abdominal  infection.  The 
lymphatics  from  the  remainder  of  the  pancreas  are  more  or  less  inde- 
pendent of  those  about  its  head,  and  do  not  drain  such  common  sites 
of  infection  as  those  already  mentioned.  The  chronic  infections  of 
the  pancreas  are  almost  always  confined  to  the  head  of  the  gland,  and 
the  fibrous  tissue  which  forms  is  interlobular  in  distribution,  thus 
corresponding  to  the  lymphatic  tissue;  it  is  true  that  the  blood-chan- 
nels also  are  interlobular,  but  if  in  these  cases  of  chronic  pancreatitis 
the  infection  was  conveyed  by  the  blood-stream  the  entire  gland  should 
be  involved,  which  is  not  the  case  in  chronic  interlobular  pancreatitis, 


ACUTE  PANCREATITIS  999 

the  common  form;  though  it  is  the  case  in  the  rarer  interacinar  form, 
in  which,  as  already  indicated,  the  causative  agent  probably  is  blood- 
borne.  That  the  infection  does  not  originate  in  the  excretory  ducts, 
in  cases  of  interlobular  pancreatitis,  is  indicated  by  the  local  dis- 
tribution of  the  resulting  fibrosis,  which  is  neither  scattered  diffusely 
throughout  the  gland,  as  are  the  ducts,  nor  yet  situated  close  about 
the  parenchyma  of  the  gland  in  the  portion  which  is  affected.  It  is 
thus  evident,  as  pointed  out  by  Maugeret  (1908),  that  the  condition 
commences  as  a  pancreatic  lymphangeitis,  the  term  suggested  by 
Arnsperger  (1911),  and  adopted  by  Deaver  and  Pfeiffer  (1912),  who 
have  been  particularly  instrumental  in  securing  recognition  of  the 
disease  in  this  country. 

4.  Infection  by  contiguity  is  rare,  except  when  a  gastric  ulcer  or 
carcinoma  becomes  adherent  to  or  perforates  into  the  pancreas. 

Acute  Pancreatitis. — Acute  catarrhal  pancreatitis  is  of  little  impor- 
tance surgically;  it  may  accompany  acute  gastroduodenitis,  and 
catarrhal  cholangeitis,  aiding  in  producing  the  obstructive  jaundice 
which  is  the  common  expression  of  these  conditions.  Acute  'paren- 
chymatous pancreatitis  is  classified  as  hemorrhagic,  suppurative,  and 
gangrenous  (Fitz,  1S89),  terms  which  indicate  the  stage  of  the  disease. 
The  suppurative  and  gangrenous  stages  frequently  are  classed  as 
subacute  pancreatitis. 

Acute  Hemorrhagic  Pancreatitis  is  the  commonest  form  of  acute 
pancreatitis.  The  adjective  hemorrhagic  is  attributive,  not  qualify- 
ing; hemorrhagic  inflammation  may  occur  in  any  organ,  but  it  is 
especially  frequent,  and  the  hemorrhagic  tendency  is  especially  marked 
in  the  case  of  the  pancreas.  It  is  probable,  as  long  ago  indicated  by 
Truhart,  that  the  process  commences  as  an  autodigestion  of  the  pan- 
creas. It  is  true  that  under  normal  conditions  the  pancreatic  juice  is 
activated  by  a  kinase  with  which  it  comes  in  contact  only  after  leav- 
ing the  pancreas;  but  under  abnormal  conditions,  as  pointed  out  by 
Carnot  (190S),  a  kinase  may  be  generated  within  the  pancreas  itself 
by  the  action  of  leukocytes  or  bacteria  or  toxins.  These,  probably, 
are  conveyed  to  the  organ  through  the  blood-stream,  for  the  lesions 
in  acute  pancreatitis  are  scattered  here  and  there,  and  are  not  confined 
to  any  particular  segment  of  the  gland.  The  results  of  the  infection 
are  caused  by  extravasation  of  the  pancreatic  juice,  whether  this  is  con- 
fined to  the  pancreas  itself  or  escapes  into  the  retroperitoneal  tissues  or 
into  the  free  peritoneal  cavity:  the  trypsin  causes  hemorrhages  and 
the  steapsin  causes  areas  of  fat  necrosis. 

The  disease  is  more  frequent  in  men  than  in  women,  and  most 
patients  are  of  middle  or  later  life,  and  rather  obese.  Recurring  slight 
attacks  are  not  very  rare,  though  the  surgeon  often  is  not  consulted 
until  a  fulminating  attack  occurs,  and  so  far  the  existence  of  the  dis- 
ease in  milder  forms  has  scarcely  ever  been  recognized.  Trauma 
has  in  some  cases  seemed  a  predisposing  cause;  in  them  a  hematoma 
probably  had  formed,  and  only  when  it  ruptured  and  allowed  extrava- 
sation of  pancreatic  juice,  did   the  symptoms  of   acute  pancreatitis 


I <HK)  SURGERY  OF   THE  PANCREAS 

arise.  If  the  abdomen  is  opened  very  early  in  the  attack  there  may 
be  nothing  to  indicate  the  pancreas  as  the  seat  of  disease;  after  the 
lapse  of  a  few  hours,  however,  there  is  found  a  sero-purulent  exudate 
usually  blood-tinged  and  areas  of  fat  necrosis  in  the  omentum,  mes- 
entery, or  peripancreatic  fat.  Hematomas  may  be  observed  in  the 
same  situations.  The  areas  of  fat  necrosis  occur  as  minute  whitish 
specks  or  flakes,  dense  and  rigid,  often  surrounded  by  a  hemorrhagic 
zone,  and  not  raised  from  the  surface  of  the  surrounding  fat,  a  fact 
which  aids  in  distinguishing  them  from  miliary  tubercles.  Disorgani- 
zation of  the  pancreas  occurs  very  early,  and  microscopical  study 
seldom  is  satisfactory,  a  fact  which  accounts  for  the  uncertainty  that 
still  exists  as  to  pathogenesis.  If  the  patient  lives,  gangrene  of  the 
pancreas  may  follow,  and  the  entire  lesser  peritoneal  cavity  may  be 
converted  into  an  abscess  containing  foul-smelling,  purulent,  chocolate 
colored  exudate,  with  pieces  of  necrotic  pancreas  floating  around  loose 
in  the  fluid. 

Symptoms  and  Clinical  Course. — Usually  symptoms  arise  so  sud- 
denly and  are  of  such  an  overwhelming  nature  that  the  patient  can 
give  no  history  of  previous  milder  attacks.  In  most  cases  seen  by 
the  surgeon  the  disease  runs  its  course  in  from  five  to  eight  days, 
death  occurring  within  a  week,  unless  prompt  operation  is  done. 
Pain,  vomiting,  and  collapse  are  the  most  prominent  symptoms.  The 
pain  is  intense,  excruciating,  and  may  cause  collapse;  it  is  neuralgic, 
and  colicky  in  nature,  and  resembles  that  due  to  acute  intestinal 
obstruction,  though  the  latter  often  begins  with  mere  twinges  and 
becomes  severe  only  after  the  lapse  of  hours.  The  pain  of  pancreatitis 
does  not  shift,  it  remains  epigastric.  Collapse  may  not  occur  until 
the  hemorrhagic  exudate  breaks  through  the  capsule  of  the  pancreas. 
Vomiting  is  so  frequently  repeated  that  it  resembles  that  which  occurs 
in  cases  of  intestinal  obstruction;  but  in  the  latter  the  vomiting  is 
projectile  and  regurgitant  and  there  is  little  or  no  nausea.  Hiccough 
is  frequent  and  very  persistent.  Dyspnea  is  said  to  be  present  rather 
often.  Physical  examination,  early  in  the  course  of  the  disease,  is 
unsatisfactory,  owing  to  tenderness  and  abdominal  distention.  Mus- 
cular rigidity  is  not  very  great.  After  the  subsidence  of  the  most  acute 
symptoms,  toward  the  third  or  fourth  day,  it  usually  is  possible  to 
detect  an  ill  defined  tumefaction  in  the  epigastrium,  and  there  fre- 
quently is  tenderness  and  perhaps  palpable  resistance  in  the  left  loin. 
The  patient  continues  to  be  gravely  ill;  the  stomach  is  unretentive; 
emaciation  is  rapid;  slight  jaundice  is  frequent;  the  pulse  is  weak 
and  running,  and  the  temperature  is  elevated  and  perhaps  hectic 
in  type.  The  patient  will  now  die  of  exhaustion,  sepsis,  or  secondary 
peritonitis,  unless  promptly  relieved  by  operation. 

Diagnosis. — Acute  pancreatitis  must  be  distinguished  from  per- 
foration of  the  stomach  or  duodenum,  biliary  colic,  intestinal  obstruc- 
tion, appendicitis,  and  poisoning  by  drugs  which  have  been  swallowed. 
In  most  cases  which  might  be  confused  with  pancreatitis,  a  history  of 
the  affection  can  be  obtained  and  will  lead  to  a  correct  diagnosis. 


CHRONIC  PANCREATITIS  1001 

Acute  pancreatitis  is  the  disease  which  cannot  be  recognized  as  any 
other  affection  and  which  is  apt,  therefore,  to  pass  undiagnosed. 

Treatment. — The  abdomen  should  be  opened  promptly  for  purposes 
of  exploration,  by  an  epigastric  incision;  isolate  the  upper  abdomen 
by  gauze  packs ;  if  a  collection  of  fluid  is  found  in  the  lesser  peritoneal 
cavity,  evacuate  it  by  aspiration;  expose  the  pancreas  (preferably 
through  the  gastro-colic  omentum),  and  if  it  presents  no  gross  lesions 
do  not  incise  it,  but  merely  tampon  the  lesser  peritoneal  cavity;  if 
there  is  an  abscess  or  hematoma  in  the  pancreas  incise  its  capsule,  and 
with  a  blunt  instrument  carry  the  incision  into  the  substance  of  the 
gland,  to  secure  drainage  of  all  pockets  of  pus,  etc.  Then  tampon 
the  incision  into  the  pancreas,  using  a  large  rubber  tube  for  drain- 
age in  the  center  of  the  tampons.  In  some  cases,  especially  of 
subacute  pancreatitis,  a  counter-incision  in  the  left  loin  should  be 
made.  Complications  in  the  biliary  tract  (which  are  not  frequent) 
should  not  be  treated  at  this  time,  except  for  very  positive  indica- 
tions. 

Abscess  or  Gangrene  of  the  Pancreas  usually  is  a  sequel  of  acute 
pancreatitis.  The  recognition  of  the  condition  depends  upon  atten- 
tion to  the  clinical  course  of  the  disease,  and  the  detection  of  evidence 
of  deep-seated  tumefaction  in  the  region  of  the  pancreas.  The  abscess 
frequently  points  in  the  left  loin,  and  if  this  is  the  case,  it  should  be 
opened  in  this  place.  In  other  cases  an  epigastric  incision  is  made 
first,  and  the  upper  abdomen  is  explored,  and  a  counter-opening  is 
made  wherever  it  seems  most  desirable.  Guinard  (1907)  commends 
the  thoracic  route  (left  side),  similar  to  that  employed  in  cases  of 
hepatic  or  subphrenic  abscess. 

Pancreatic  Fistula  sometimes  persists  for  a  long  time  after  an  opera- 
tion for  acute  pancreatitis.  The  discharge  is  exceedingly  irritating 
and  the  skin  should  be  protected  by  ointments  with  mineral  base. 
Antidiabetic  diet  should  be  insisted  upon,  as  advocated  by  Wolge- 
muth  (1912);  then  usually  the  discharge  decreases  rapidly  after  a 
week  or  ten  days,  and  the  fistula  closes. 

Chronic  Pancreatitis. — This  may  be  catarrhal  or  interstitial  in  dis- 
tribution. The  former  is  believed  by  Mayo  Robson  and  others  to  be 
of  frequent  occurrence,  though  it  is  of  slight  surgical  significance; 
it  frequently  accompanies  chronic  interstitial  pancreatitis,  and  when 
duct-borne  infection  was  regarded  as  frequent  the  catarrhal  was 
believed  to  be  a  forerunner  of  the  interstitial  form.  Chronic  inter- 
stitial jmncreatitis  occurs  in  two  main  forms:  intcracinar  and  inter- 
lobular. The  former  was  mentioned  at  p.  998,  as  accompanying 
arteriosclerotic  changes  in  the  pancreas;  the  lesions  involve  the  entire 
pancreas  (head,  body,  and  tail),  the  nutrition  of  the  islands  of  Langer- 
hans  is  affected  early,  and  diabetes  often  results.  It  is  not  amenable 
to  surgical  treatment. 

The  only  variety  of  this  disease  of  surgical  importance  is  chronic 
interlobular  pancreatitis.  As  already  pointed  out  this  begins  as  a 
pancreatic  lymphangeitis,  the  primary  focus  usually  being  in  the  gall- 


1002  SURGERY  OF   THE  PANCREAS 

bladder  or  ducts,  or  in  the  pyloric  region  of  the  stomach  or  duodenum. 
If  the  primary  focus  of  infection  can  be  recognized  and  properly 
treated  before  the  process  in  the  pancreas  has  advanced  to  the  stage 
of  organization  and  cicatrization  (true  chronic  interlobular  pancrea- 
titis),  there  is  every  reason  to  believe  that  the  pancreas  will  not  be 
permanently  damaged.  The  disease  is  commonest  in  adult  males 
between  thirty  and  fifty  years  of  age. 

Symptoms  and  Clinical  Course. — The  symptoms  of  pancreatic  lym- 
phangeitis  are  those  of  the  causative  lesion,  and  the  local  pancreatic 
changes  are  not  recognized  until  after  the  abdomen  has  been  opened. 
Then  the  head  of  the  pancreas  is  found  enlarged,  firmer  than  normal, 
and  the  individual  lobules  are  distinctly  palpable,  which  is  not  the 
case  in  the  normal  pancreas.  In  true  interlobular  pancreatitis,  the 
advanced  stage  of  pancreatic  lymphangeitis,  the  head  of  the  pancreas 
(the  body  and  tail  are  scarcely  ever  affected,  for  reasons  already 
pointed  out)  is  enlarged  and  hard  with  a  nodular  surface;  on  section, 
tense  bands  of  fibrous  tissue  traverse  the  cut  surfaces,  accounting 
for  the  formation  of  the  well-marked  lobules.  In  some  cases  the  en- 
largement of  the  head  of  the  organ  can  be  detected  through  the 
abdominal  walls.  The  symptoms  are  those  of  the  underlying  malady, 
accompanied  by  certain  additional  symptoms  and  physical  signs  and 
certain  changes  in  the  digestive  functions  which  characterize  the 
condition  as  one  of  pancreatic  insufficiency.  Moreover,  whenever  the 
enlarged  head  of  the  pancreas  obstructs  the  common  bile  duct  (which 
traverses  it  in  two-thirds  of  cases),  there  are  added  symptoms  of 
biliary  insufficiency,  namely,  obstructive  jaundice,  and  its  accompany- 
ing digestive  derangements.  The  consequences  of  pancreatic  insuffi- 
ciency are  chiefly  steatorrhea,  and  azotorrhea: 

Steatorrhea  is  an  excess  of  fat  in  the  feces.  It  is  seldom  that  this 
is  visible  to  the  naked  eye.  In  well-marked  cases  of  steatorrhea  the 
passages  are  bulky,  of  a  silver,  gray,  or  asbestos-like  color,  and  the 
fat  may  float  on  the  surface  like  oil  droplets  or  particles  of  butter. 
But  such  stools  occasionally  occur  in  health  after  ingestion  of  large 
quantities  of  fatty  food;  and  in  slighter  degrees  steatorrhea  may  be 
caused  by  biliary  deficiency,  diarrhea,  and  other  intestinal  derange- 
ments, so  that  too  much  reliance  cannot  be  placed  on  it  as  an 
indication  of  pancreatic  insufficiency. 

Azotorrhea. — This  is  an  excess  in  the  feces  of  undigested  proteid 
material.  This  condition  occurs,  according  to  Fitz,  only  when  there 
is  extreme  diminution  of  the  pancreatic  juice,  and  is  significant  only 
when  gastric  digestion  is  normal,  when  the  diet  contains  no  excess  of 
meat,  and  when  there  is  no  diarrhea. 

The  presence  of  stercobilin  in  the  feces  indicates  that  there  is  not 
complete  obstruction  to  the  discharge  of  bile  into  the  intestines.  In 
cases  of  obstructive  jaundice  due  to  chronic  pancreatitis  and  common 
duct  lithiasis  the  obstruction  is  rarely  absolute,  and  a  distinct  though 
often  subnormal  reaction  for  stercobilin  may  be  obtained:  but  in 
carcinoma  of  the  head  of  the  pancreas  it  is  entirely  absent  or  present 
only  in  very  faint  traces. 


CHRONIC  PANCREATITIS  1003 

It  is  much  simpler  to  determine  the  presence  or  absence  of  biliary 
and  pancreatic  secretions  in  the  intestinal  canal  by  analysis  of  the 
duodenal  contents  secured  through  a  tube  passed  by  mouth  (Rehfuss). 

Urinary  Changes.- — As  already  noted  glycosuria  seldom  occurs  in 
interlobular  pancreatitis  and  when  present  in  this  condition  appears 
only  very  late  and  usually  indicates  an  incurable  lesion.  "  Alimentary 
Glycosuria"  (that  which  occurs  when  an  excess  of  sugar  is  ingested) 
is  much  more  apt  to  occur,  and  may  be  a  constant  phenomenon,  if 
there  is  serious  disease  of  the  pancreas  (Wille's  test).  In  interacinar 
pancreatitis  glycosuria  is  a  very  frequent  and  an  early  symptom,  but 
this  disease  is  not  amenable  to  surgical  treatment. 

A  "pancreatic  reaction"  in  the  urine  was  described  by  Cammidge 
(1901),  but  most  surgeons  have  come  to  regard  it  as  valueless. 

Diagnosis  of  Chronic  Pancreatitis. — Pancreatitis  is  to  be  regarded  as 
a  complication  of  some  other  disease  rather  than  as  an  independent 
affection,  and  it  cannot  be  too  often  emphasized  that  the  curable 
stage  of  the  pancreatic  affection  vanishes  when  the  lymphangeitic  infil- 
tration and  edema  give  place  to  an  interlobular  sclerosis  which  can 
be  no  more  curable  than  chronic  nephritis  or  cirrhosis  of  the  liver. 

From  the  symptoms  and  physical  signs,  localization  of  the  disease 
to  the  pancreatico-hepatic  region  almost  always  can  be  made,  but  in 
the  differentiation  of  chronic  pancreatitis  from  disease  of  the  bile 
ducts  there  always  is  a  large  amount  of  doubt. 

Treatment. — This  may  almost  be  summarized  in  the  expression 
treat  the  cause.  In  most  cases  the  cause  is  in  the  gall-bladder  or  bile- 
ducts,  and  prolonged  drainage  of  the  biliary  tract  allows  subsidence 
of  the  pancreatic  swelling,  by  overcoming  the  focus  of  infection  to 
which  it  was  due.  It  is  not  an  uncommon  thing  for  a  biliary  fistula 
to  remain  open  for  months,  or  for  symptoms  to  recur  if  it  closes  too 
early,  in  cases  of  chronic  pancreatitis.  Mayo  Robson  and  some 
other  surgeons  prefer  to  adopt  cholecystenterostomy  (p.  989)  as  a 
primary  operation  in  such  cases;  but  it  seems  more  logical  to  attempt 
to  relieve  the  biliary  infection  which  is  present  by  external  rather 
than  by  intestinal  drainage.  The  gall-bladder  should  be  sutured  to  the 
parietal  peritoneum  or  the  anterior  sheath  of  the  rectus,  as  described 
at  p.  986,  and  the  resulting  fistula  should  be  kept  open  for  several 
months;  and  it  is  important  at  the  time  of  operation  if  the  patient's 
condition  permits  to  make  sure  of  the  patency  of  the  common  duct 
by  passing  a  sound  through  it  into  the  duodenum. 

In  some  cases  of  pancreatitis  no  primary  lesion,  not  even  a  slight 
one,  can  be  found  in  the  biliary  tract.  The  pyloric  region  of  the 
stomach  or  the  duodenum  may  then  be  the  focus  of  infection,  and  if 
this  is  determined  to  be  the  case,  such  lesions  should  receive  appro- 
priate treatment.  When  no  other  lesion  can  be  discovered  Vautrin 
(1908)  advocates  attacking  the  pancreas  directly,  and  especially  urges 
drainage  of  the  retropancreatic  tissues  after  exposing  this  region  by 
mobilization  of  the  duodenum  (p.  988). 


1004  SURGERY  OF  THE  PANCREAS 

Pancreatic  Calculi. — These  are  of  such  rarity  and  so  seldom  produce 
recognizable  symptoms,  that  they  are  of  comparatively  slight  surgical 
importance.  The  pathogenesis  of  the  stones  is  similar  to  that  of  biliary 
calculi,  but  their  composition  is  very  different,  most  pancreatic  calculi 
being  formed  largely  of  calcium  carbonate  or  phosphate.  They  are 
not  crystalline,  usually  occur  in  large  numbers  strung  along  the  pan- 
creatic ducts  like  the  beads  of  a  chain,  and  are  faceted  only  on  their 
ends.  They  occur  five  times  as  often  in  men  as  in  women,  but  have 
been  diagnosed  during  life  in  very  few  recorded  instances.  There  may 
be  symptoms  of  coincident  (and  perhaps  causative)  biliary  disease, 
or  of  pancreatic  insufficiency;  and  as  the  calculi  are  impermeable  to 
the  ar-ray  it  might  be  possible  to  recognize  their  shadows  in  a  skia- 
graph; pancreatic  colic,  if  it  occurs,  can  scarcely  be  distinguished 
from  that  due  to  biliary  disease. 

Treatment. — Link  (1911)  collected  six  operations  for  pancreatic 
calculi,  and  reported  a  seventh  operation  by  himself.  He  performed 
pancreastostomy  (analogous  to  cholecystostomy)  drawing  the  tail 
of  the  pancreas  out  through  the  transverse  mesocolon,  splitting  the 
gland  longitudinally,  removing  the  calculi,  and  stitching  a  rubber 
drainage  tube  in  the  principal  duct.  The  fistula  was  still  open  several 
months  after  the  operation,  but  the  patient  was  in  good  health. 

Carcinoma. — Carcinoma  is  the  most  frequent  tumor  of  the  pancreas. 
It  affects  the  head  of  the  organ  in  more  than  half  the  cases,  corre- 
sponding thus  with  chronic  interlobular  pancreatitis,  though  there  is 
so  far  no  proof  that  the  latter  disease  is  an  etiological  factor  in  the 
production  of  carcinoma.  The  tumor  begins  as  a  very  small  localized 
growth,  usually  as  scirrhus,  and  sometimes  gives  metastases  to  the 
liver  before  it  grows  large  enough  to  be  readily  recognized;  hence  many 
cases  of  secondary  carcinoma  of  the  liver  are  considered  primary 
until  a  minute  primary  nodule  is  found  in  the  pancreas.  If  the  growth 
occurs  in  such  a  situation  as  to  block  the  excretory  duct  of  the  pan- 
creas and  to  occlude  the  common  bile-duct  the  resemblance  to  other 
causes  of  obstructive  jaundice  (common  duct  lithiasis,  chronic  pan- 
creatitis, tumors  or  strictures  of  the  choledochus)  is  very  close,  and 
differential  diagnosis  may  be  difficult.  In  most  cases,  however,  of 
malignant  obstruction  of  the  common  duct  the  gall-bladder  becomes 
enlarged  (Courvoisier's  Law,  p.  981),  and  in  very  many  cases  can  be 
easily  recognized  through  the  abdominal  wall  as  a  globular  tumor, 
moving  with  respiration,  and  continuous  with  the  liver  dulness  which 
often  also  is  greater  than  normal. 

Symptoms  and  Diagnosis. — There  are  no  pathognomonic  symptoms. 
The  original  clinical  description,  given  by  Bard  and  Pic  (1888)  (which 
comprised  steadily  increasing  jaundice,  enlargement  of  the  gall-bladder 
and  rapid  emaciation),  constitutes  a  syndrome  or  group  of  symptoms 
common  to  any  lesion  which  causes  obstruction  at  the  papilla  of 
Vater  (Fig.  991).  A  carcinoma  of  the  pancreas  may  grow  in  situations 
other  than  the  head  of  the  gland  without  producing  this  syndrome, 
and  various  other  conditions  may  cause  obstruction  at  the  papilla 


CARCINOMA 


1005 


of  Vater  and  thus  give  rise  to  this  same  group  of  symptoms.  In  the 
typical  case  of  carcinoma  in  the  head  of  the  pancreas,  a  patient, 
usually  over  forty  years  old,  complains  for  an  indefinite  period  of 
vague  upper  abdominal  symptoms  having  no  localizing  character. 
Then  jaundice  appears  painlessly,  and  continuously  deepens;  the 
gall-bladder  enlarges,  and  the  patient  loses  weight  and  strength  very 
rapidly.  Pain  may  or  may  not  be  a  conspicuous  feature.  Fever 
usually  is  absent.  Jaundice  never  lessens,  but  continuously  grows 
deeper;  signs  of  insufficiency 
of  the  pancreas  are  present, 
and  its  secretions  are  never 
found  in  the  duodenum. 

When  the  abdomen  is 
opened  and  the  pancreas  is 
examined  directly  by  sight 
and  touch,  it  often  is  impos- 
sible to  differentiate  carci- 
noma and  pancreatitis.  In 
most  cases  reliance  must  be 
placed  on  the  clinical  history 
of  the  disease.  In  pancrea- 
titis the  usual  cause  is  biliary 
infection,  which  seldom  is 
present  in  carcinoma.  In 
pancreatitis  there  are  recur- 
rent attacks  of  pain,  fever, 
jaundice,  characteristic  of 
stone  in  the  common  duct; 
while  in  carcinoma  the  onset 
is  insidious,  the  course  of 
the  disease  is  chronic,  and 
there  are  no  periods  of  re- 
mission. In  pancreatitis  the 
gall-bladder  is  contracted 
and  friable,  and  usually  is 
surrounded  by  adhesions;  in 
carcinoma  it  is  enlarged  and 
distended,  and  is  much  more 
tough  and  resistant  than  in 
cases  of  pancreatitis. 

Treatment. — Palliative  operations  (cholecystostomy  and  cholecyst- 
enterostomy  are  those  available)  do  not  prolong  the  patient's  life 
but  may  promote  his  comfort.  Radical  operation,  which  scarcely  ever 
is  possible,  consists  in  excision  of  the  head  of  the  pancreas  (cephalic 
pancreatectomy).  This  implies  also  resection  of  the  descending 
duodenum,  as  removal  of  the  pancreas  jeopardizes  its  blood  supply. 
The  technique,  which  was  systematized  by  Desjardins  (1907)  and  Sauve 
(1908),  comprises  section  of  the  pylorus,  mobilization  of  the  duodenum, 


Fig.  991.  —  Obstructive  jaundice:  enlarge- 
ment of  the  gall-bladder  and  liver,  probably 
from  carcinoma  of  the  head  of  the  pancreas. 
An  inoperable  case.  German  Hospital.  (Deaver 
and  Ashhurst.) 


1006  SURGERY  OF   THE  PANCREAS 

section  of  the  duodenum  on  the  righl  of  the  superior  mesenteric  artery, 
division  of  the  pancreas  (well  beyond  the  growth),  and  section  of  the 
common  bile-duct.  Then  it  remains  to  reestablish  the  continuity 
of  the  gastro-intestinal  tract  by  gastrojejunostomy;  to  in  plant 
the  choledochus  into  the  intestine  or  stomach;  and  finally  to  drain 
the  remaining  portion  of  the  pancreas  into  the  intestine  (pancreato- 
enterostomy, Coffey,  1909).  It'  the  tumor  is  in  the  body  of  the 
pancreas,  the  organ  may  he  resected  and  its  two  ends  reunited,  as 
done  by  Finney;  or  if  the  tail  only  is  involved,  it  may  he  removed 
and  the  stump  closed. 

Cysts  of  the  Pancreas. — These  are  classed  as  true  cysts  (those  due 
to  retention,  cystic  neoplasms,  hydatid  cysts,  etc.)  and  'pseudo-cysts 
(cysts  which  arise  in  close  association  with  the  pancreas  and  involve 
it  secondarily).  Pseudo-cysts  are  more  frequent  than  true  cysts, 
and  usually  are  formed  by  effusions  which  result  from  abdominal 
injuries. 

The  affection  is  commonest  in  early  adult  life,  and  in  many  cases 
a  history  of  traumatism  can  be  obtained,  though  it  may  have  occurred 
several  years  previously.  The  existence  of  retention  cysts,  the  result 
of  occlusion  of  the  ducts  by  calculi  or  chronic  pancreatitis,  is  so  rare 
that  it  is  of  pathological  interest  only.  Cystic  new  growths  also  are 
rare,  whether  benign  or  malignant,  and  the  cysts  which  result  seldom 
are  large.  Traumatic  cysts  form  the  vast  majority  of  cases  seen  by 
the  surgeon,  and  they  are  frequently  situated  in  the  lesser  peritoneal 
cavity,  having  only  secondary  connections  with  the  pancreas.  The 
contents  of  the  cyst  usually  are  light  brown,  being  tinged  by  the  blood 
in  the  original  hematoma,  or  from  hemorrhage  into  the  cyst  at  a 
later  period;  and  examination  often  detects  the  presence  of  one  or 
more  of  the  pancreatic  ferments. 

Symptoms  and  Diagnosis. — Apart  from  rather  vague  digestive 
symptoms  and  recurring  attacks  of  acute  epigastric  pain,  there  is 
little  on  which  to  base  a  diagnosis  until  a  tumor  can  be  detected,  or 
at  least  until  it  is  of  such  size  as  to  cause  pressure  symptoms.  The 
hitter  comprise  gastric  symptoms,  with  recurring  attacks  of  pain 
and  vomiting;  jaundice  from  biliary  obstruction;  and  constipation 
from  pressure  on  the  colon.  Symptoms  of  pancreatic  insufficiency 
are  rather  unusual.  The  tumor  which  finally  develops  may  present 
through  the  gastro-colic  omentum,  through  the  gastro-hepatic  omentum, 
or  below  the  transverse  colon.  The  relation  of  the  stomach  and  colon 
to  the  cyst  may  be  determined  by  percussion,  after  distending  these 
organs  with  air,  or  by  skiagraphy.  In  rare  cases  the  cyst  may  grow 
backward  into  either  flank.  Most  cysts  transmit  the  pulsations 
of  the  aorta,  but  this  ceases  when  the  patient  assumes  the  knee- 
chest  posture.  Disappearance  of  a  cyst  may  result  from  its  rupture 
into  the  intestinal  tract,  whereupon  large  quantities  of  saliva-like 
fluid  are  discharged  from  the  bowel;  usually  the  cyst  refills. 

A  pancreatic  cyst  must  be  distinguished  from  mesenteric  and  omental 
cysts;  from  kidney,  suprarenal  and  hepatic  cysts;  from  an  enlarged 


GENERAL  DIAGNOSIS  OF  ABDOMINAL  TUMORS  1007 

gall-bladder;  from  ovarian  cysts;  from  cysts  of  the  spleen;  and  from 
aneurysm  of  abdominal  aorta.  As  a  rule  the  history,  the  relation 
existing  between  the  stomach  and  colon  and  possibly  signs  of  pan- 
creatic insufficiency,  make  the  diagnosis  fairly  certain  in  most  cases. 
Treatment. — Operation  is  indicated,  as  there  is  no  hope  of  spon- 
taneous cure.  If  the  cyst  is  small  and  pedunculated  (which  is  rare) 
it  may  be  possible  to  extirpate  it  completely.  In  most  cases  mar- 
supialization must  be  done — the  cyst  being  evacuated  and  its  cavity 
being  drained  with  gauze  and  tube.  Closure  of  the  resulting  fistula 
may  be  accelerated  by  adherence  to  an  antidiabetic  diet. 

SURGERY    OF    THE    SPLEEN. 

Most  of  the  conditions  which  are  of  surgical  interest  cause  an 
enlargement  of  the  spleen,  and  it  is  important  to  be  able  to  differentiate 
an  enlarged  spleen  from  other  abdominal  tumors. 

General  Diagnosis  of  Abdominal  Tumors. — Splenic  Tumors. — These 
may  be  almost  of  any  size,  even  filling  the  greater  part  of  the 
abdomen.  In  most  cases,  however,  the  enlargement  is  greatest  on  the 
left  side,  and  the  spleen  unless  fixed  by  adhesions,  moves  with  respir- 
ation. The  enlarged  spleen  is  so  closely  applied  to  the  abdominal 
wall  that  it  is  impossible  to  insinuate  the  hand  between  its  upper 
margin  and  the  costal  border;  it  has  a  sharp  inner  border  which  is 
almost  always  interrupted  by  one,  two,  or  three  notches.  Splenic 
tumors  always  grow  forward;  they  never  produce  fulness  in  the  loin. 
The  dulness  on  percussion  extends  up  to  the  sixth  rib  or  higher  in 
the  mid-axillary  line.  The  colon  is  first  displaced  downward,  and  later 
lies  behind  the  enlarged  spleen,  so  that  any  resonance  due  to  it  will 
be  in  the  flank  or  loin.  In  many  cases  of  splenic  enlargement  the 
blood  examination  aids  in  making  a  diagnosis. 

Kidney  Tumors  rarely  come  into  close  contact  with  the  anterior 
abdominal  wall,  and  even  when  they  do,  they  also  cause  marked 
bulging  in  the  loin.  They  have  a  rounded  contour,  with  no  sharp, 
notched  anterior  border.  The  range  of  motion  is  much  less  than  in 
the  case  of  the  spleen,  and  the  tumor  does  not  move  with  respiration. 
In  all  but  the  very  largest  tumors  the  hand  can  be  insinuated  between 
the  costal  margin  and  the  upper  border  of  the  kidney.  The  descending 
colon  overlies  the  anterior  surface  of  the  kidney  and  is  pushed  forward 
when  the  kidney  enlarges.  Thus  there  is  resonance  anterior  to  the 
tumor  and  dulness  in  the  loin,  which  is  the  reverse  of  what  is  present 
in  the  case  of  a  tumor  of  the  spleen.  Other  important  differential 
signs  are  obtained  by  cystoscopy,  catheterization  of  the  ureters,  and 
examination  of  the  urine. 

Suprarenal  Growths  give  much  the  same  physical  signs  as  kidney 
tumors,  but  the  colon  often  is  pushed  downward  instead  of  forward. 
Hematuria  is  frequently  present. 

Periphrenic  Abscess,  apart  from  evidences  of  suppuration,  resembles 
enlargement  of  the  kidney  rather  than  splenic  tumor. 


K  IDS  SURGERY  OF   THE  SPLEEN 

Ovarian  Tumors.— In  the  case  of  a  wandering  spleen  of  nearly  normal 
size,  which  has  become  fixed  in  the  pelvis,  confusion  might  arise  unless 
a  distinct  notch  could  be  felt.  In  other  cases  ovarian  and  splenic 
tumors  could  scarcely  be  confused.  The  upper  border  of  an  ovarian 
tumor  is  very  seldom  in  actual  contact  with  the  left  costal  margin  unless 
it  reaches  also  to  the  right  costal  margin.  Ovarian  tumors  grow 
upward  from  the  pelvis;  they  do  not  move  with  respiration;  and  have 
no  sharp  border  with  one  or  more  notches.  They  extend  further 
across  the  middle  line  and  cause  more  symmetrical  enlargement  of 
the  abdomen.  Vaginal  examination  shows  the  tumor  in  close  associa- 
tion with  a  normal  sized  uterus,  and  frequently  the  pedicle  of  the  cyst 
can  be  felt  through  the  rectum.  There  is  usually  an  area  of  resonance 
between  the  upper  border  of  dulness  over  an  ovarian  tumor  and  the 
normal  area  of  splenic  dulness. 

Growths  of  the  Colon  at  the  Splenic  Flexure. — Most  of  these  tumors 
cause  intestinal  obstruction  before  a  palpable  tumor  develops,  but 
occasionally  a  diffuse  non-obstructing  carcinoma  occurs  which  may 
have  to  be  differentiated  from  an  atypical  enlargement  of  the  spleen. 
A  tumor  of  the  colon  has  not  the  definite  shape  of  an  enlarged  spleen, 
nor  has  it  the  same  close  apposition  to  the  abdominal  wall  throughout 
its  extent.  It  usually  is  dull  to  superficial  and  resonant  to  deep  per- 
cussion. It  seldom  moves  much  during  respiration,  but  unless  fixed 
by  adhesions  changes  its  position  to  a  marked  extent  with  changes  in 
the  patient's  posture.  Sooner  or  later  intestinal  obstruction  and  metas- 
tasis  develop,  but  exploratory  laparotomy  should  be  done  before  this 
stage  is  reached. 

Tuberculous  Peritonitis. — In  this  condition,  already  studied  in  Chap- 
ter XXII,  tumors  of  various  sizes  and  shapes  may  form  in  the  abdomen, 
and  one  which  forms  in  the  left  hypoehondrium,  particularly  if  adherent 
to  the  spleen,  may  closely  simulate  a  splenic  tumor.  But  the  range 
of  motion  is  limited  by  adhesions,  and  although  the  anterior  border 
of  such  a  mass  may  feel  quite  sharp  and  well  defined,  it  seldom  ex- 
hibits a  notch  similar  to  those  on  the  spleen.  Moreover,  other  foci  of 
tuberculosis  often  can  be  detected,  and  the  tuberculin  test  may  be  of 
value. 

Retroperitoneal  Tumors  are  comparatively  rare.  The  least  unusual 
variety  is  a  diffuse  lipoma,  which  is  clinically  semi-malignant,  tending 
to  recur  after  partial  extirpation.  Complete  extirpation  is  not  possible. 
Sarcoma  also  occurs  as  a  retroperitoneal  tumor,  usually  arising  in 
the  lymph  nodes.  These  retroperitoneal  tumors  usually  present  within 
the  circle  formed  by  the  large  bowel,  offering  to  percussion  a  dull  note 
surrounded  by  intestinal  tympany.  Inflation  of  the  stomach  and 
colon,  and  exmination  in  the  Trendelenburg  and  knee-chest  positions 
should  be  employed  in  obscure  cases. 

Splenic  Diseases  Requiring  Surgical  Treatment. — At  present  almost 
the  only  form  of  surgical  treatment  adopted  in  cases  of  splenic  disease 
is  splenectomy;  but  in  resorting  to  splenectomy  in  the  treatment  of 
diseases  of  the  spleen,  surgeons  should  disabuse  their  minds  of  the 


ABSCESS  OF  THE  SPLEEN  1009 

idea  that  there  is  anything  miraculous  or  even  mysterious  in  the 
procedure.  Removal  of  the  spleen  can  be  indicated  only  for  diseases 
in  which  it  is  at  fault.  In  the  present  state  of  knowledge  it  is  safe  to 
indicate : 

1.  Cases  in  which  splenectomy  may  be  necessary:  Movable  spleen, 
cysts,  abscess,  tumors,  tuberculosis,  Banti's  disease,  hemolytic  icterus 
(congenital  and  acquired);  and  perhaps  some  early  cases  of  leukemia 
and  pernicious  anemia. 

2.  Cases  in  which  splenectomy  is  contra-indicated:  Most  cases  of 
malaria,  the  leukemias,  pernicious  anemia,  splenomegalic  polycy- 
themia, typhoid  fever,  syphilis,  kala-azar;  congestion,  infarct  and 
thrombosis,  infectious  fever,  Hodgkin's  disease,  cases  of  portal  obstruc- 
tion,  amyloid  disease,   pseudoleukemia. 

If  it  can  be  shown  in  the  future,  in  any  other  than  the  diseases  above 
enumerated,  that  the  spleen  is  at  fault,  then  splenectomy  will  become 
a  legitimate  method  of  treatment  for  those  conditions. 

Movable  Spleen. — This  occurs  oftenest  in  women,  as  in  the 
somewhat  analogous  condition  of  hepatoptosis,  already  described. 
Increased  weight,  from  enlargement,  prediposes  the  spleen  to  ptosis, 
but  in  many  cases  of  enlarged  spleen  adhesions  hold  the  organ  in 
place.  A  movable  spleen  is  of  surgical  importance  chiefly  because 
of  the  accidents  to  which  it  is  subject,  notably  acute  torsion  of  its 
pedicle.  This  is  accompanied  by  paroxysmal  pain,  with  reflex  vomit- 
ing, shock,  and  perhaps  by  the  later  development  of  gangrene  of  the 
spleen  and  peritonitis.  In  chronic  torsion  the  twist  of  the  pedicle  is 
tight  enough  only  to  cause  congestion  of  the  spleen  which  leads  to 
perisplenic  adhesions.  Recurrent  acute  attacks  may  lead  to  the 
same  results,  and  the  spleen  may  become  fixed  in  an  abnormal  position, 
a  condition  described  as  dislocated  spleen. 

Diagnosis. — The  diagnosis  of  a  movable  spleen  is  made  by  recogniz- 
ing in  the  movable  tumor  the  size,  consistency,  and  shape  of  the 
normal  spleen,  and  by  the  possibility  of  the  reduction  of  the  spleen 
to  its  normal  position  when  the  patient  is  recumbent.  The  diagnosis 
of  a  dislocated  spleen  is  difficult,  owing  to  the  adhesions  which  obscure 
its  shape. 

Treatment. — If  no  symptoms  are  produced  it  is  sufficient  for  the 
patient  to  wear  an  abdominal  support  which  will  tend  to  keep  the 
spleen  in  place.  In  most  cases  where  symptoms  are  present,  splenec- 
tomy is  indicated.     Splenopexy  does  not  give  satisfactory  results. 

Cysts  of  the  Spleen. — Hydatid  cysts  are  extremely  rare.  By  far 
the  greater  number  of  splenic  cysts  are  non-parasitic  in  type,  and 
most  are  the  result  of  traumatism,  though  lymphangeiomatous  and 
sequestration  cysts  may  occur,  as  well  as  cystic  degenerations  following 
embolism.  The  symptoms  are  those  usual  in  cases  of  splenomegaly 
and  the  diagnosis  depends  on  recognition  of  the  cystic  character  of 
the  enlargement.     The  most  satisfactory  treatment  is  splenectomy. 

Abscess  of  the  Spleen  may  occur  in  pyemia,  but  cases  of  surgical 
interest  usually  develop  in  the  course  of  some  infectious  fever,  espe- 
6-i 


1010  SURGERY  OF   THE  SPLEEN 

cially  malaria,  and  rarely  typhoid,  dysentery,  influenza,  and  dengue. 
These  abscesses  usually  arc  single  and  of  large  size.  The  diagnosis 
depends  on  recognition  of  enlargement  of  the  spleen  with  general  and 
local  signs  of  suppuration.  Treatment  usually  must  be  confined  to 
incision  and  drainage,  since  perisplenic  adhesions  render  splenectomy 
difficult  or  impossible. 

Splenic  Anemia,  or  Banti's  Disease,  described  by  Banti  in  1888, 
is  characterized  by  great  chronicity  and  three  definite  clinical  and 
pathological  stages:  (1)  Simple  enlargement  of  the  spleen.  (2)  Enlarge- 
ment with  secondary  anemia.  (3)  Cirrhosis  of  the  liver  with  spleno- 
megaly. The  cause  of  the  disease  is  unknown,  but  it  is  believed  to 
be  infectious  in  origin.  The  great  majority  of  cases  begin  in  early 
adult  life,  and  the  sexes  are  about  equally  affected.  The  disease 
extends  over  a  period  of  from  five  to  twenty-five  years,  and  always 
terminates  fatally  unless  the  spleen  is  removed. 

Pathology. — The  spleen  enlarges  steadily  but  retains  its  normal 
shape.  The  average  weight  is  from  1500  to  1750  grams.  Usually 
numerous  and  dense  perisplenic  adhesions  develop,  and  the  capsule 
and  fibrous  trabecular  of  the  spleen  undergo  hypertrophy,  but  the 
most  notable  change  is  hyperplasia  of  the  reticular  fibers  without  any 
marked  change  in  the  cellular  elements.  The  amount  of  endothelial 
proliferation  may  be  so  great  as  to  cause  the  characteristic  change 
known  as  Primitive  Endothelioma  of  the  Type  of  Gaucher  (1882).  The 
splenic  vein  is  always  more  or  less  sclerosed,  and  this  change  may  also 
affect  the  portal  vein.  Cirrhosis  of  the  liver  does  not  develop  until  late 
in  the  second  stage  of  the  disease,  and  from  this  time  on  the  changes 
cannot  be  distinguished  from  those  of  Laennec's  atropic  cirrhosis. 

Symptoms  and  Diagnosis. — The  first  stage  (simple  enlargement  of  the 
spleen)  develops  insidiously  and  lasts  a  long  time.  There  is  enlarge- 
ment of  the  spleen  which  may  not  be  discovered  until  it  is  of  great 
size,  but  no  other  symptoms  exist.  In  the  second  stage  there  are  added 
to  the  splenic  enlargement  symptoms  of  anemia  (pallor,  weakness, 
dyspnea,  palpitation).  The  anemia  is  of  the  chlorotic  type— diminu- 
tion of  red  blood  cells  and  hemoglobin  with  a  low  color  index.  There 
is  also  leukopenia  with  relative  lymphocytosis.  But  the  symptoms 
of  anemia  may  be  out  of  all  proportion  to  the  blood  changes.  The 
amount  of  urine  is  decreased,  and  it  contains  urobilin  and  albumin 
intermittently.  Finally  the  liver  begins  to  enlarge,  and  subsequently 
or  even  previous  to  palpable  enlargement  of  the  liver,  gastro-intestinal 
hemorrhages  (particularly  hematemesis)  occur.  This  second  stage 
of  the  disease  lasts  from  eighteen  months  to  several  years.  With 
the  approach  of  the  third  stage  the  liver  diminishes  in  size,  ascites 
develops,  the  hemorrhages  increase,  the  urine  is  still  further  diminished 
and  contains  urobilin  and  at  times  bilirubin,  the  skin  develops  pig- 
mentation and  sometimes  toward  the  end  of  the  disease  true  jaundice 
occurs. 

Much  dispute  as  to  minor  points  still  exists,  but  the  above  descrip- 
tion gives  the  essentials  of  the  clinical  course  of  the  disease.     The 


SPLENECTOMY 


1011 


diagnosis  usually  is  impossible  in  the  first  stage,  which  often  is  classed 
as  "idiopathic  splenomegaly."  Even  after  the  appearance  of  anemia 
differential  diagnosis  may  be  difficult.  In  cirrhosis  of  the  liver  gastro- 
intestinal hemorrhages  and  ascites  with  decrease  in  size  of  the  liver 
usually  appear  before  enlargement  of  the  spleen.  In  pernicious  anemia 
the  anemia  is  greater  than  in  Banti's  disease,  the  color  index  is  high, 
and  nucleated  red  blood  cells  and  poikilocytes  are  present.  In  Banti's 
disease  the  hemoglobin  seldom  is  below  40  per  cent,  unless  there  has 
been  a  recent  severe  hemorrhage,  as  in  Morris  Lewis's  case.  In  malarial 
splenomegaly  the  parasite  usually  can  be  found  in  the  blood,  the  history 
of  the  case  is  different,  and  quinine  may  be  curative.  Leukemia  is 
disclosed  by  the  blood  examination.  Splenomegaly  in  childhood  (Fig. 
992)  is  very  difficult  to  distinguish  from  Banti's  disease.  Some  of  the 
cases  probably  are  Banti's  disease.  The  pseudoleukemia  infantium  of 
von  Jaksch  usually  appears  in  the  second  year  of  life,  is  characterized 
by  very  grave  anemia  (red  blood  cells,  1,000,000;  normoblasts;  poikilo- 
cytosis),  by  leukocytosis  (15,000  to 
20,000)  and  lymphocytosis.  There  is 
marked  splenomegaly  and  usually 
moderate  enlargement  of  the  liver. 
Banti's  disease  must  also  be  distin- 
guished from  syphilitic  splenomegaly, 
amyloid  spleen,  and  horn  family  types 
of  splenomegaly  in  childhood.  Hemo- 
lytic splenomegaly,  recently  described 
by  Banti,  which  resembles  both 
Banti's  disease  and  hemolytic  jaun- 
dice, is  cured  promptly  by  splenec- 
tomy. 

Treatment. — The  only  treatment 
which  has  any  effect  on  the  disease 
is  removal  of  the  spleen,  and  this  is 
effective  only  if  done  before  cirrhosis 
of  the  liver  (third  stage  of  disease) 
develops.  The  presence  of  slight 
ascites,  with  enlargement  of  the  liver, 
which  occurs  in  the  end  of  the  second 
stage  of  the  disease  is  not  a  contra- 
indication to  splenectomy,  as  these 
symptoms  do  not  indicate  irremedi- 
able changes  in  the  liver.  The  immediate  mortality  of  splenectomy 
is  lowest  in  the  first  stage  of  the  disease,  and  increases  the  longer 
the  operation  is  postponed.  The  average  immediate  mortality  is  about 
25  per  cent.;  permanent  cure  results  in  almost  all  cases  where  oper- 
ation is  done  in  the  first  stage,  in  from  50  to  75  per  cent,  of  those  in 
the  second  stage,  and  in  few  or  no  cases  in  the  third  stage. 

Splenectomy.-  The  best  incision  is  one  on  the  left  corresponding 
to    the    gall-bladder    incision.     If    no    adhesions    are    present    the 


Fig.  992. — Splenomegaly  in  a  child 
aged  three  and  a  half  years.  (Dr. 
Newlin's  case.)  Pennsylvania  Hos- 
pital. 


1012  SURGERY  OF  THE  SPLEEN 

operation  is  not  difficult.  The  most  important  point  is  the  control 
of  hemorrhage.  The  capsule  of  the  spleen  and  the  veins  in  its  pedicle 
are  easily  torn.  It  is  best  if  possible  to  separate  adhesions  first,  and 
to  cut  the  lienophrenic  ligament  and  then  rotate  the  spleen  toward 
the  mid-line.  If  the  hand  can  be  introduced  gently  between  the  spleen 
and  diaphragm,  the  former  may  be  drawn  down  into  the  wound. 
If  the  vessels  in  the  pedicle  are  not  too  large  they  should  be  clamped 
close  to  the  spleen,  and  the  spleen  removed  after  cutting  between  the 
clamps  and  the  spleen.  In  some  cases  the  tail  of  the  pancreas  is  cut 
off  also  (Mayo),  but  if  carefully  sutured  no  fistula  will  result.  Unless 
there  is  enough  tissue  left  in  the  pedicle  for  the  safe  application  of 
ligatures  it  is  best  to  leave  the  clamps  in  place  for  several  days.  J.  C. 
A.  Gerster  (1915)  suggests  ligation  of  the  main  trunk  of  the  splenic 
artery  through  an  opening  in  the  gastrohepatic  omentum.  In  most 
cases  it  is  well  to  leave  a  gauze  drain  in  the  wound. 


CHAPTER  XXV 

SURGERY  OF  THE  BLADDER  AND  KIDNEYS. 

Genito -urinary  surgery  has  been  developed  into  such  a  specialty 
of  late  years  that  it  is  impossible  in  a  text-book  such  as  this  to  do  more 
than  indicate  in  the  briefest  possible  manner  the  general  principles 
of  diagnosis  and  treatment  of  most  of  the  affections,  and  to  describe 
in  somewhat  greater  detail,  but  by  no  means  at  full  length,  those 
conditions  of  common  occurrence  which  are  constantly  encountered 
in  general  practice. 

GENERAL  DIAGNOSIS   OF  URINARY  DISORDERS. 

The  surgeon  must  study  the  urine  or  other  secretions  discharged 
from  the  urethra,  and  examine  the  genito-urinary  organs  themselves.  A 
thorough  examination  includes  maeroscopical  and  microscopical  study 
of  urethral  discharges  (both  those  which  are  apparent,  and  those 
obtained  after  stripping  the  prostate  and  seminal  vesicles,  p.  1069); 
chemical  and  microscopical  study  of  the  urine,  which  should  be 
collected  in  three  glasses  for  maeroscopical  inspection;  instrumentation 
with  sound  or  catheter;  and  cystoscopic  examination.  In  many  cases 
bacteriological  study  of  the  urine,  pus,  etc.,  also  is  necessary. 


Fig.  993. — 1,  soft  rubber  catheter.      2,  metal  catheter. 

Catheters. — Catheters  are  hollow  tubes  designed  to  draw  off  the 
contents  of  the  bladder  (Fig.  993).  If  they  are  of  metal  (usually 
nickel-plated)  they  must  have  a  curve  corresponding  to  that  of  the 
urethra.  Sir  Henry  Thompson's  instruments  were  curved  at  the 
point  through  an  arc  which  corresponds  to  the  fourth  of  the  circum- 
ference of  a  circle  whose  diameter  is  8.25  cm.  Flexible  catheters 
have  no  fixed  curve;  they  are  of  two  principal  kinds:  the  soft  rubber 
catheter  (Nekton's),  and  the  English  catheter.  The  latter  is  made 
of  webbing  and  is  covered  with  shellac.  It  is  provided  with  a  stylet, 
and  when  used  with  tin's  in  place,  is  fairly  rigid;  or  if  used  without  the 

(1013) 


1014  SURGERY  OF  THE  BLADDER  AND  KIDNEYS 

stylet,  as  is  safer  and  customary,  may  be  made  to  retain  any  curve  for 
a  short  time  by  moulding  it  in  warm  water  and  then  quickly  plunging 
it  into  cold  water  when  it  becomes  stiff.  A  catheter  should  be  25 
to  28  cm.  long,  and  provided  with  one  or  two  large,  smoothly 
finished  eyes  near  its  vesical  extremity;  all  catheters  should  be  solid 
from  the  eye  to  the  point,  thus  leaving  no  pocket  for  the  accumula- 
tion of  decomposing  blood  or  inspissated  pus.  An  English  catheter 
should  have  the  eye  woven  in  its  manufacture,  not  punched  out  after 
the  catheter  has  been  made;  and  if  used  with  the  stylet,  great  care 
must  be  taken  not  to  have  the  stylet  so  long  that  there  is  danger  of  it 
protruding  from  the  eye.  The  caliber  of  urethral  instruments  usually 
is  based  on  the  French  scale,  which  gives  the  diameter  in  thirds  of  a 
millimeter  (practically  the  circumference  in  millimeters).  The  sizes 
in  common  use  range  from  10  to  40;  the  average  adult  urethra  accom- 
modates a  sound  of  from  30  to  32  Fr.  A  rigid  instrument  smaller  than 
No.  10  is  dangerous  and  should  not  be  used. 

Introduction  of  the  Catheter. — The  greatest  damage  may  be  inflicted 
from  neglect  of  proper  antiseptic  and  aseptic  precautions.  Metallic 
and  soft  rubber  instruments  may  be  boiled  just  before  use;  but  as 
webbing  instruments  will  be  ruined  by  heat,  they  should  be  soaked  in 
a  5  per  cent,  solution  of  formalin  (cold)  for  twenty  minutes  and  before 
being  used  should  be  rinsed  in  cold  sterile  water,  as  the  formalin  solu- 
tion might  cause  urethritis.  The  patient  should  be  lying  down; 
and  the  surgeon  after  washing  his  own  hands  (and  wearing  gloves  if 
possible)  should  retract  the  patient's  foreskin,  and  wash  the  glans  well 
with  soap  and  water  and  rinse  it  in  alcohol.  The  instrument  should 
be  well  lubricated  with  some  sterile  oil,  such  as  a  preparation  of  Irish 
moss,  or  glycerin;  and  it  often  is  well  to  distend  the  urethra  by  inject- 
ing the  lubricant  directly  into  it  from  a  syringe.  A  soft  catheter  is 
introduced  by  inserting  its  point  in  the  meatus  and  gently  pushing 
it  onward  into  the  bladder  little  by  little,  always  holding  it  close  to 
the  glans  penis.  A  metallic  instrument  is  most  easily  inserted  while 
the  surgeon  stands  at  the  patient's  left.  After  raising  the  penis  in  the 
left  hand  the  surgeon  gently  inserts  the  tip  of  the  instrument  within 
the  meatus,  while  its  shaft  lies  along  the  left  groin.  Then  without 
raising  the  shaft  from  the  plane  of  the  body,  it  is  carried  over  to  the 
mid-line,  as  the  tip  of  the  instrument  sinks  into  the  penile  urethra; 
it  should  enter  by  its  own  weight  and  should  not  be  forced.  Not 
until  the  point  has  reached  the  bulbous  urethra  should  the  handle 
be  raised  from  the  patient's  abdomen.  As  the  handle  is  gently  raised 
the  point  glides  under  the  pubis,  traverses  the  prostate,  and  enters 
the  bladder  (Fig.  994).  If  the  handle  is  raised  too  soon  the  point 
will  catch  in  front  of  the  triangular  ligament.  When  the  point  has 
successfully  passed  this  region,  and  the  handle  of  the  instrument  is 
nearly  vertical,  the  left  hand  may  be  placed  on  the  convexity  of  the 
instrument,  in  the  perineum,  and  thus  guide  it  into  the  bladder. 
When  the  catheter  has  entered  the  bladder  it  can  be  rotated  freely  in 
the  urethra,  on  its  own  axis,  and  its  shaft  lies  between  the  patient's 


GENERAL  DIAGNOSIS  OF  URINARY  DISORDERS 


1015 


thighs  making  an  angle  of  45°  or  less  with  the  horizon.  An  instrument 
may  also  be  passed  from  the  patient's  right  side  by  the  manoeuvre 
known  as  the  tour  de  maitre:  the  instrument  is  introduced  with  its 
convexity  upward,  and  as  its  point  reaches  the  bulb  the  shaft  is 
swept  around  toward  the  abdomen,  and  is  raised  to  the  vertical  and 
then  depressed  between  the  patient's  thighs  as  the  instrument  enters 
the  bladder. 


Fig.  994. — Method  of  introducing  a  metal  catheter. 

Cystoscopes. — A  cystoscope  is  an  instrument  designed  to  permit 
visual  inspection  of  the  interior  of  the  bladder.  In  the  female  it  is 
possible  to  accomplish  this  by  direct  vision,  using  a  narrow  speculum 
(Kelly's  cystoscope)  and  placing  the  patient  in  the  knee-chest  or 
exaggerated  Trendelenburg  position  so  as  to  allow  the  bladder  to 
become  distended  with  air  so  soon  as  the  speculum  is  introduced.    In 


Fig.  995. — Illumination  of  anterior  vesical  wall  by  Nitze's  cystoscope.      (Park.) 


men,  however,  it  is  necessary  to  have  an  instrument  somewhat  resem- 
bling a  catheter,  provided  with  an  electric  light  at  its  vesical  extremity 
and  a  series  of  lenses  by  which  the  image  is  transferred  to  the  outer 
end  of  the  instrument  where  the  examiner's  eye  is  placed  (Fig.  995). 
In  most  cystoscopes,  the  system  of  lenses  reverses  the  image,  but  by 
inserting  another  lens,  the  image  may  be  righted  again;  this,  however, 


Ill  Hi  SURGERY  OF   THE  BLADDER  AND  KIDNEYS  . 

makes  the  apparatus  more  complicated  and  cuts  down  the  amount  of 
light.  Cystoscopic  examination  requires  skill  and  practice,  and  should 
not  be  attempted  without  ample  training.  In  many  cases  it  may  be 
accomplished  after  anesthetizing  the  deep  urethra  with  a  4  per  cent. 
solution  of  eucain,  but  sometimes  a  general  anesthetic  is  required. 
Before  the  cystoscope  is  inserted  the  bladder  should  be  emptied  of 
urine,  and  irrigated  if  necessary  to  cleanse  it  of  blood  or  pus;  about 
four  ounces  of  solution  are  left  in  the  bladder.  Then  the  cystoscope 
(sterilized  in  carbolic  acid  or  formalin  solution — it  cannot  be  boiled) 
is  introduced,  and  after  its  point  is  within  the  bladder,  the  electric 
current  is  turned  on,  and  the  examiner  proceeds  to  inspect  the  interior 
of  the  bladder.  The  ureteral  orifices  may  be  seen  and  the  swirl  of 
urine  discharged  from  each  may  be  readily  recognized,  as  also  the  dis- 
charge of  blood  or  pus  instead  of  urine.  The  condition  of  the  vesical 
mucous  membrane  is  also  studied;  foreign  bodies,  tumors  or  calculi 
are  searched  for;  the  presence  and  situation  of  the  orifices  of  diverticula 
are  located,  etc.  Some  cystoscopes  are  provided  with  slots  through 
which  a  fine  catheter  may  be  passed,  for  the  purpose  of  catheterizing 
the  ureters;  and  through  some  it  is  possible  to  insert  delicate  instru- 
ments and  under  the  control  of  vision  make  applications  to  ulcers, 
cauterize  or  snare  off  tumors,  remove  small  foreign  bodies,  etc.  An 
endoscope  is  an  instrument  similar  to  a  cystoscope,  but  designed  to 
examine  the  interior  of  the  urethra. 

Estimation  of  the  Functional  Capacity  of  the  Other  Kidney. — Always 
before  one  kidney  is  removed,  and  in  a  great  many  other  cases,  it  is 
necessary  for  the  surgeon  to  determine  the  functional  capacity  of  the 
healthy  (or  less  diseased)  kidney.  The  simplest  way  to  do  this  is  by 
chromoureteroscopy,  by  means  of  the  indigo-carmine  test;  this  was 
introduced  in  1903  by  Volcker  and  Joseph,  and  has  been  popularized 
in  this  country  by  B.  A.  Thomas:  20  c.c.  of  a  0.4  per  cent,  solution,  or 
4  c.c.  of  a  4  per  cent,  solution  of  indigo-carmine  are  injected  hypoder- 
mically,  and  a  cystoscope  is  introduced.  The  urine  is  stained  blue, 
and  if  the  kidney  is  healthy  the  stain  will  appear  in  the  urine  as  it  is 
discharged  from  the  ureter  of  the  kidney  in  question  within  nine 
minutes  of  the  time  it  was  injected  hypodermically.  A  delay  of  more 
than  twenty  minutes  in  the  appearance  of  the  stain  indicates  serious 
incompetency. 

Other  methods  involve  the  collection  of  urine  from  each  kidney 
separately.  This  is  best  accomplished  by  catheterization  of  the  ureters. 
Then  one  may  use,  in  addition  to  the  ordinary  chemical  and  micro- 
scopical tests  of  the  separate  urines,  also  what  is  known  as  the 
yhenolsidyhonephthalein  test,  which  is  thus  described  by  H.  H.  Young: 
"The  patient  is  given  three  glasses  of  water  to  drink,  and  is  then 
catheterized  and  the  bladder  washed  out  just  before  inserting  1  c.c. 
of  fluid  containing  6  mg.  of  the  drug  intramuscularly  or  intravenously. 
The  time  of  the  appearance  of  the  first  faint  pinkish  tinge  as  the  urine 
escapes  from  the  catheter  into  the  test-tube,  made  alkaline  by  adding 
a  drop  of  25  per  cent.  NaOH  solution,  is  noted  as  the  beginning  of  the 


SURGERY  OF  THE  BLADDER  1017 

test."  In  healthy  patients  the  drug  appears  in  the  urine  about  seven 
minutes  after  it  is  administered;  40  to  60  per  cent,  is  excreted  in  the 
first  hour,  and  from  20  to  25  per  cent,  in  the  second  hour.  In  addition 
to  these  tests  for  the  eliminating  powers  of  the  kidneys,  tests  are 
now  coming  into  use  to  determine  the  retention  in  the  blood  of  meta- 
bolic products  which  normally  are  excreted  by  the  kidneys  (blood 
urea) ;  but  so  far  they  have  not  met  with  general  acceptance. 

SURGERY  OF  THE  BLADDER. 

Exstrophy  of  the  Bladder  is  a  congenital  deformity  due  to  a  defect 
in  the  closure  of  the  hypogastric  region  of  the  abdominal  wall.  The 
pubic  bones  often  are  ununited,  and  epispadias  (p.  1101)  and  sometimes 
inguinal  hernia  may  also  be  present.  The  deformity  is  much  commoner 
in  male  than  in  female  children.  The  anterior  wall  of  the  bladder 
being  absent,  the  intra-abdominal  pressure  forces  out  the  posterior 
wall,  and  the  mucous  surface  presents  itself  as  a  red,  moist  protrusion, 
often  with  the  ureteral  orifices  readily  visible.  Urine  dribbles  con- 
stantly, the  mucous  membrane  and  surrounding  skin  become  much 
inflamed,  and  ascending  infection  of  the  kidneys  almost  invariably 
follows;  it  is  said  that  in  about  half  the  cases  death  ensues  from  this 
complication  before  the  tenth  year. 

The  only  effective  treatment  is  by  operation,  of  which  there  are  two 
main  classes: 

1.  Those  which  aim  to  cover  in  the  protruding  bladder  wall  by  some 
form  of  plastic  operation.  Of  these  methods  the  best  is  that  of  John 
Wood  (1865),  in  which  a  cutaneous  flap  from  below  the  umbilicus 
is  inverted  over  the  bladder,  and  is  covered  by  two  flaps  slid  inward 
from  the  groins,  or  by  one  large  "bridge  flap"  from  the  scrotum 
(Richard).  Though  this  does  not  restore  sphincteric  control,  it 
narrows  the  opening  for  the  discharge  of  urine  and  makes  it  possible 
for  the  patient  to  be  kept  clean  by  wearing  a  urinal;  but  in  many 
cases  cystitis  occurs  and  vesical  calculi  form,  and  ascending  kidney 
infection  causes  death.  Moreover,  if  hairs  grow  on  the  inverted  skin 
surface  they  cause  additional  trouble. 

2.  The  other  plan  of  operation,  and  that  which  is  most  in  favor 
at  the  present  day,  consists  in  transplanting  the  ureters  or,  preferably, 
the  base  of  the  bladder  containing  the  ureteral  orifices,  into  the  large 
bowel  (rectum  or  sigmoid),  thus  allowing  the  urine  to  collect  in  the 
rectum  where  it  may  be  retained  by  the  sphincter  several  hours  at  a 
time.  Here  also,  however,  there  is  great  danger  of  ascending  kidney 
infection,  even  when  the  valve-like  insertion  of  the  ureters  in  the 
bladder  wall  remains  intact  in  the  transplanted  segment;  and  the 
primary  mortality  is  even  higher  than  in  the  autoplastic  methods. 

Urachal  Cysts  and  Fistulae. — If  the  allantoic  duct  of  the  embryo 
fails  to  close  at  the  umbilicus  a  fistula  remains  which  may  discharge 
urine  if  it  is  patent  all  the  way  down  to  the  bladder,  or  which  if  closed 
at  its  vesical  end  may  discharge  only  mucoid  fluid.     Sometimes  a 


Mils  SURGERY   OF  THE  BLADDER  AND  KIDNEYS 

fistula  of  the  urachus  will  close  spontaneously  after  obstruction  to  the 

natural  outflow  of  urine  is  removed,  bul  in  most  eases  excision  of  the 
fistulous  tract  is  required.  If  the  urachus  closes  at  both  ends,  a  cyst 
may  form  in  its  course.  These-  urachal  cysts  seldom  give  rise  to 
recognizable  symptoms,  and  usually  arc  found  unexpectedly  at 
operation.     Excision  is  the  proper  treatment  for  both  cysts  and  fistula?. 

Cystitis.— Inflammation  of  the  urinary  bladder  in  almost  all  cases 
is  caused  by  bacteria,  which  are  introduced  from  without  or  which 
reach  it  through  the  urine  delivered  from  the  kidneys.  Unless  there 
is  obstruction  to  the  outflow  of  urine  through  the  urethra  it  is  difficult 
to  infect  the  healthy  bladder  with  germs  of  ordinary  virulence,  and 
bacteriuria  (see  below)  may  exist  a  long  time  without  the  occurrence 
of  cystitis.  An  ordinary  mild  attack  of  cystitis  tends  to  spontaneous 
recovery;  but  the  occurrence  of  congestion  of  the  bladder  (from  internal 
medication,  exposure  to  cold,  instrumentation,  etc.)  predisposes  it  to 
infection,  as  does  the  presence  of  foreign  bodies  (calculi).  Unclean, 
or  even  clean  catheterization,  if  frequently  repeated,  is  the  most 
frequent  cause  of  cystitis;  but  extension  backward  of  an  acute  or 
chronic  urethritis,  or  the  descent  from  the  kidney  of  urine  contaminated 
with  tubercle  or  typhoid  bacilli,  are  other  usual  causes.  Colon  bacilli 
are  those  most  often  introduced  by  instrumentation. 

The  usual  changes  met  with  in  inflammation  of  mucous  surfaces 
are  present:  an  abundant  mucous  secretion,  desquamation  of  epithe- 
lium, and  if  the  infection  is  severe,  ulceration  of  the  bladder.  Perfora- 
tion is  excessively  rare.  In  cases  of  long  standing,  infiltration  of  the 
bladder  wall  occurs,  the  muscular  coat  is  more  or  less  replaced  by 
fibrous  tissue,  and  as  this  contracts  the  capacity  of  the  bladder  is 
much  decreased  and  its  elasticity  is  destroyed. 

Symptoms. — Pain,  frequency  of  urination,  and  changes  in  the  com- 
position of  the  urine,  are  the  cardinal  symptoms  of  cystitis.  The 
pain,  which  is  felt  mostly  in  the  perineum  or  behind  the  pubis,  varies 
with  the  acuteness  of  the  attack,  and  may  be  present  only  during 
urination,  or  there  may  be  a  constant  burning  or  sense  of  weight. 
The  urine  is  passed  frequently,  in  small  quantities,  and  with  consider- 
able tenesmus;  it  is  clouded  by  pus  and  mucus,  and  occasionally  is 
blood-stained.  The  pus  will  cloud  all  the  urine,  whether  this  is  collected 
in  one,  two,  or  more  glasses.  In  acid  urines  are  found  the  B.  coli 
communis,  B.  tuberculosis,  B.  typhosus,  pneumococcus,  and  gono- 
coccus;  in  alkaline  urines,  staphylococci,  streptococci,  B.  proteus,  etc. 
Constitutional  symptoms  are  unusual  except  in  very  severe  grades 
of  acute  cystitis,  and  they  often  indicate  renal  complications. 

Treatment.— As  already  noted,  most  cases  of  cystitis  tend  to  spon- 
taneous recovery  unless  there  is  urethral  obstruction,  or  unless  the 
infecting  source  continues  active.  The  first  point  in  treatment  is  to 
determine  the  source  of  infection  and  remove  it.  If  no  exterior  source 
can  be  determined,  and  if  no  urinary  obstruction  exists,  it  is  probable 
that  the  kidney  is  at  fault.  If  cystoscopy  cannot  be  done  the  fact 
that  the  cystitis  has  its  origin  in  an  infected  kidney  often  must  be 


DIVERTICULA  1019 

surmised  only  by  exclusion  of  all  other  factors,  and  by  noting  pain 
and  tenderness  over,  and  perhaps  enlargement  of  the  kidney. 

In  the  Acute  Stages. — Put  the  patient  to  bed  and  keep  him  on  a 
liquid  diet,  with  plenty  of  water,  and  some  demulcent  such  as  flaxseed 
tea.  If  the  urine  is  alkaline,  give  three  or  four  times  daily  benzoic 
acid  (0.3  gm.)  kept  in  solution  by  adding  twice  the  quantity  of  sodium 
bicarbonate.  When  acidity  has  been  secured,  phenyl  salicylate  or 
hexamethylenamin  may  be  administered.  If  the  urine  is  too  acid,  an 
alkaline  diuretic  should  be  given,  such  as  potassium  citrate  or  acetate. 
If  there  is  much  pain  or  violent  tenesmus,  no  hesitation  should  be 
felt  in  giving  opium  and  belladonna  by  rectal  suppositories  or  hypo- 
dermically.  Local  hot  applications  (sitz-baths)  are  grateful  to  the 
patient;  and  in  case  retention  of  urine  (p.  1170)  occurs,  every  such 
method  should  be  tried  before  resorting  to  catheterization,  and  if  this 
becomes  necessary  only  a  soft  instrument  should  be  used. 

When  the  chronic  stage  is  reached  much  good  may  be  accom- 
plished by  irrigation  of  the  bladder.  Saline  or  boric  acid  solution 
may  be  used  in  ordinary  cases,  and  in  more  rebellious  cases  per- 
manganate of  potash  (1  to  8000)  or  silver  nitrate  solutions  (1  to 
2000  up  to  1  to  100).  Irrigation  of  the  Bladder  is  best  accomplished 
through  a  soft  catheter,  to  the  outer  end  of  which  a  small  funnel  is 
attached;  the  fluid  is  then  allowed  to  run  in  gently  by  the  force  of 
gravity.  By  inserting  a  nozzle  just  within  the  meatus,  and  raising 
the  reservoir  to  a  height  of  from  1  to  \\  meters,  it  is  possible  to 
overcome  the  sphincter  and  irrigate  the  bladder  without  the  intro- 
duction of  a  catheter;  but  unless  very  skilfully  done  this  method  is 
more  painful.  Not  more  than  60  to  75  c.c.  should  be  introduced  at 
first,  but  after  several  sittings  which  should  take  place  every  second 
or  third  day,  the  amount  may  be  increased  up  to  the  tolerance  of  the 
bladder.  The  surgeon  should  not  imagine,  however,  that  he  is  opera- 
ting by  a  species  of  hydraulic  mining,  and  no  force  whatever  must 
be  employed.  In  chronic  cystitis  with  urinary  obstruction  it  often  is 
well  to  let  the  catheter  remain  in  place,  thus  securing  better  drainage; 
and  as  a  last  resort  it  may  be  necessary  to  perform  suprapubic  or 
perineal  cystotomy  to  secure  free  drainage. 

Bacteriuria. — Bacteriuria  is  a  condition  in  which  bacteria  are  found 
in  large  quantities  in  the  urine,  but  in  which  local  symptoms  are 
slight  or  absent.  The  bacteria  most  often  encountered  are  the  colon 
and  typhoid  bacillus  and  the  Staphylococcus  albus.  The  source  which 
supplies  the  bacteria  (kidney,  prostatic  urethra)  should  be  deter- 
mined and  suitably  treated.  Bladder  irrigations  are  of  no  use;  but 
deep  injections  into  the  prostatic  urethra,  or  irrigation  of  the  kidney 
pelvis  after  catheterization  of  the  ureter,  usually  prove  efficient. 
When  no  source  of  infection  can  be  detected,  a  prolonged  course  of 
urinary  antiseptics,  or  administration  of  autogenous  vaccines  may 
prove  curative. 

Diverticula. — Diverticula  of  the  bladder  sometimes  occur  in  cases 
of  chronic  cystitis,  usually  as  the  result  of  back  pressure  from  urethral 


1020  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

obstruction.  They  are  most  frequent  on  the  extraperitoneal  surface 
of  the  bladder.  The  urine  which  collects  in  them  stagnates,  and 
calculi  frequently  form.  Occasionally  perforation  occurs.  The  diag- 
nosis is  best  made  by  cystoscopy;  but  occasionally  the  presence  of 
a  diverticulum  may  be  suspected  if  residual  urine  is  found  sometimes 
but  is  entirely  absent  at  other  times,  or  if  after  washing  out  the 
bladder  until  the  solution  returns  clear,  a  sudden  gush  of  purulent 
urine  occurs.     Radiography  is  also  of  value. 

Treatment. — The  only  satisfactory  treatment  is  excision  of  the  diver- 
ticulum; at  the  same  time,  or  previously,  all  causes  of  urinary  obstruc- 
tion should  be  overcome.  If  operation  is  refused,  temporary  improve- 
ment may  be  secured  by  vesical  irrigation  and  treatment  of  the  urinary 
obstruction. 

Tuberculosis. — Tuberculosis  of  the  bladder  almost  always  is  sec- 
ondary to  the  disease  elsewhere  in  the  body,  especially  in  the  kidney 
or  epididymis.  Although  constantly  exposed  to  infection  when  the 
secretions  of  these  organs  enter  it,  the  bladder  successfully  resists 
infection  for  a  long  time,  and  even  when  infected  is  able  for  a  long 
time  to  recover  its  health  spontaneously  if  the  source  of  infection  is 
removed.  If  this  source  is  the  kidney,  the  vesical  lesion  begins  around 
the  ureteral  orifice;  while  if  infection  is  received  from  the  ejaculatory 
ducts  through  the  urethra,  the  vesical  trigone  is  the  part  first  affected. 
The  affected  areas  are  at  first  mere  patches,  of  congestion ;  then  whitish 
tuberculous  nodules  appear,  break  down,  and  form  small  round  ulcers 
which  tend  to  preserve  this  typical  rounded  form  even  when  they 
have  coalesced.  Advent  of  mixed  infection  causes  rapid  spread  of 
the  lesions 

Symptoms. — Frequency  of  urination  is  the  earliest,  and  for  a  long 
time  may  be  the  only  subjective  symptom,  though  blood  in  micro- 
scopic quantities  usually  will  be  found  in  the  urine  if  looked  for.  As 
the  process  advances,  urination  becomes  excessively  painful,  there  is 
great  and  incessant  tenesmus,  and  the  pain  is  referred  to  the  end  of 
the  penis,  the  thighs,  and  the  perineum.  The  urine  is  acid,  increased 
in  quantity,  and  in  time  becomes  intermittently  or  constantly  bloody 
and  shreddy.  By  this  time  signs  of  tuberculosis  elsewhere  in  the 
body  usually  have  appeared.  The  detection  of  tubercle  bacilli  in  the 
urine  may  be  very  difficult,  but  inoculation  experiments  may  serve 
to  confirm  the  diagnosis. 

Treatment. — In  addition  to  the  general  treatment  suitable  in  every 
case  of  tuberculosis,  it  usually  is  possible  to  cause  arrest  or  even 
complete  cure  of  the  vesical  lesion,  if  the  primary  focus  (kidney, 
testicle,  etc.)  is  removed.  Even  if  both  kidneys  are  diseased,  it  seems 
that  the  removal  of  the  more  diseased  organ  improves  the  condition, 
not  only  of  the  bladder,  but  of  the  remaining  kidney.  In  cases  in 
which  the  disease  seems  primary  in  the  bladder,  local  treatment  may 
be  relied  on.  Bransford  Lewis  recommends  injections  into  the  bladder 
of  iodoform  emulsion,  or  distention  of  the  bladder  by  air.  As  a  last 
resort  suprapubic  drainage  may  be  adopted  to  promote  euthanasia. 


VESICAL  CALCULUS  1021 

Tumors  of  the  Bladder,  except  papilloma  and  carcinoma,  are  rare. 
In  children  sarcoma  sometimes  is  seen.  Pathologically,  papilloma 
is  a  benign  neoplasm,  but  clinically  it  resembles  malignant  tumors 
in  its  tendency  to  recurrence,  and  according  to  some  authorities  it 
frequently  undergoes  carcinomatous  transformation.  So  long  as  it 
is  benign  clinically  it  forms  a  more  or  less  pedunculated  villous 
tumor,  with  a  base  which  moves  freely  on  the  muscular  wall  of  the 
bladder.  Carcinoma  is  hard,  nodular,  infiltrating,  and  becomes  fixed 
to  surrounding  structures,  such  as  prostate  or  vagina. 

Symptoms. — The  earliest  symptom  of  a  vesical  tumor  is  hematuria, 
which  is  usually  painless  at  first,  and  characterized  by  the  irregularity 
of  its  occurrence.  It  may  be  profuse,  and  eventually  causes  grave 
secondary  anemia.  Malignant  tumors  may  be  excessively  painful,  so 
that  examination  without  a  general  anesthetic  may  prove  impossible. 
The  usual  occurrence  of  cystitis  adds  its  symptoms  to  those  due  to 
the  vesical  tumor  itself.  The  diagnosis  is  best  made  by  cystoscopy, 
taking  means  to  secure  a  clear  medium  by  the  local  use  of  adrenalin 
to  check  bleeding  or  by  constant  irrigation.  If  this  is  impossible, 
suprapubic  cystotomy,  which  often  is  required  for  treatment,  may  be 
used  for  diagnosis. 

Treatment. — Small  and  well  pedunculated  papillomas  may  be  re- 
moved by  the  operating  cystoscope  by  snaring  and  cauterization  of 
their  bases.  Larger  or  recurrent  growths  require  suprapubic  cystotomy, 
with  wide  excision  of  mucosa  with  the  pedicle,  the  wound  being 
cauterized  and  the  bladder  drained.  Malignant  growths  require  ex- 
cision of  the  entire  thickness  of  the  bladder  wall.  Sometimes  this 
involves  extirpation  of  the  bladder,  with  transplantation  of  the 
ureters  into  the  rectum  or  the  skin  of  the  loin;  or  bilateral  nephros- 
tomy may  be  done.  The  mortality  is  about  30  per  cent.,  and  about 
half  the  patients  have  recurrence  within  a  year.  Fulguration  is  effi- 
cient in  many  benign  tumors,  and  may  be  repeated  in  case  of  recur- 
rence, and  often  is  useful  as  a  palliative  measure  in  otherwise 
inoperable  conditions. 

Vesical  Calculus. — The  pathogenesis  of  urinary  calculi  is  discussed 
in  connection  with  kidney  stones  (p.  1032).  The  majority  of  vesical 
calculi  have  descended  from  the  kidneys  where  they  were  originally 
formed.  Such  stones  are  composed  of  uric  acid,  having  been  formed 
in  acid  (uninfected)  urine.  But  while  lying  in  the  bladder  they  may 
subsequently  become  encrusted  with  triple  phosphates,  if  the  urine  is 
alkaline  and  cystitis  is  present.  Pure  phosphatic  calculi  may  also  be 
formed  in  the  bladder,  under  the  conditions  just  mentioned.  Calculi 
of  amorphous  phosphates,  however,  are  formed  in  urine  which  is  alka- 
line or  neutral  when  it  leaves  the  kidney,  and  are  not  caused  by  vesical 
infection  and  alkaline  decomposition  of  urine  in  the  bladder  as  are 
those  composed  of  triple  phosphates.  Calculi  of  oxalate  of  lime  (called 
mulberry  calculi  from  their  appearance)  are  next  most  frequent  to 
calculi  composed  of  uric  acid  and  triple  phosphates,  which  together 


L022  SURGERY  OF   THE  BLADDER  AND   KIDNEYS 

form  90  per  cent,  of  all  urinary  calculi,  more  than  half  of  all  calculi 
1  icing  uric  acid. 

Vesical  calculus  is  more  frequent  in  men,  and  in  children,  than  in 
women.  In  women  and  children  phosphatic  calculi  are  very  rare. 
Calculi  vary  in  size  from  those  just  too  large  to  he  passed  spontaneously 
to  those  which  fill  the  bladder.  Calculi  small  enough  to  be  passed 
through  the  urethra  (usually  less  than  1  gram  in  weight)  are  classed 
as  gravel.  A  calculus  weighing  more  than  75  to  100  grams  is  rare. 
Usually  only  one  calculus  is  present,  and  very  seldom  are  there  more 
than  five  or  six. 

The  chief  predisposing  causes  for  the  formation  of  calculi  in  the 
bladder  arc  urinary  obstruction  and  vesical  infection.  Hence  most 
phosphatic  calculi  are  met  with  in  cases  of  stricture  of  the  urethra 
and  enlargement  of  the  prostate.  Foreign  bodies  in  the  bladder 
(broken  ends  of  catheters,  etc.)  usually  become  encrusted  with  phos- 
phates owing  to  the  development  of  cystitis.  If  there  is  no  obstruc- 
tion and  the  urine  remains  acid,  stones  very  rarely  form  in  the  bladder, 
and  those  which  descend  from  the  kidney  may  be  passed  by  urethra. 

Symptoms. — Pain  and  hematuria  are  the  chief  symptoms.  The  pain 
is  characterized  by  two  features:  (1)  It  is  made  worse  by  motion, 
exercise,  jolting,  etc.,  and  (2)  it  occurs  especially  at  the  end  of 
urination,  when  the  bladder  contracts  on  the  calculus.  The  pain 
is  felt  in  the  neck  of  the  bladder  and  is  referred  mostly  to  the  glans 
penis,  and  sometimes  to  the  perineum,  rectum  or  thighs.  Persist- 
ent tenesmus  may  produce  prolapse  of  the  rectum  or  hemorrhoids. 
Sometimes  hyperacid  urine,  in  the  absence  of  calculi,  may  cause  similar 
symptoms;  and  sometimes  a  calculus  lodged  in  a  diverticulum  or 
behind  an  enlarged  prostate  may  be  so  fixed  as  to  cause  no  distinctive 
symptoms.  Bleeding  occurs  irregularly,  rarely  being  profuse.  It  is 
increased  by  motion,  and  seldom  appears  except  at  the  end  of  urina- 
tion.    The  blood  is  bright  red,  as  if  recent. 

Diagnosis. — The  diagnosis  of  vesical  calculus  depends  upon  detecting 
the  stone  by  a  sound,  by  cystoscopy,  or  by  skiagraphy  (Fig.  996). 
A  vesical  sound,  or  stone  searcher  (Fig.  999)  resembles  an  ordinary 
urethral  sound  except  that  its  shaft  is  smaller  and  longer,  and  its  beak 
shorter  and  more  abruptly  curved.  Before  sounding  about  125  c.c.  of 
fluid  should  be  injected  into  the  bladder,  if  this  has  been  recently  emp- 
tied. First  explore  the  center  of  the  bladder  and  then  turn  the  beak 
to  each  side  in  turn,  giving  gentle  taps  by  quickly  rotating  the  instru- 
ment between  thumb  and  finger.  Finally  depress  the  shaft  between 
the  patient's  thighs,  reverse  the  beak,  and  explore  the  bas-fond  of  the 
bladder,  particularly  in  cases  of  enlarged  prostate,  by  gently  raising  the 
shaft  again.  The  presence  of  more  than  one  calculus  may  be  ascer- 
tained by  catching  one  in  the  blades  of  a  lithotrite  (Fig.  997),  and  then 
striking  the  other  with  the  instrument.  If  the  calculus  is  lodged  in 
a  diverticulum,  or  covered  by  mucus  or  blood  clot,  it  may  be  impos- 
sible to  detect  it  by  a  sound;  and  sometimes  phosphatic  incrustations 
on  the  bladder  wall  are  mistaken  for  a  calculus. 


VESICAL  CALCULUS 


1023 


In  most  cases  skiagraphy  is  available,  and  will  demonstrate  the 
number  and  size  of  all  but  the  softest  stones.  Cystoscopy  is  not  often 
required. 


Fig.  996. — Vesical  calculus  in  a  boy  aged  four  years.     (Dr.  J.  P.  Hutchinson's 
case.)     Children's  Hospital. 


Fig.  997. — Lithotrite  crushing  stone.     (Watson  and  Cunningham.) 

Treatment. — The  stones  must  be  removed.  There  is  no  solvent 
treatment. 

Lithotrity  and  Litholayaxy. — Unless  the  stones  are  very  hard  (mul- 
berry calculus)  they  may  be  broken  up  into  gravel  inside  the  bladder 


L02  I 


SURGERY  OF   THE  BLADDER   AND  KIDNEYS 


by  means  of  the  lithotrite,  the  operation  being  known  as  lithotrity 
(Civiale,  1824);  the  fragments  are  left  to  be  passed  spontaneously. 
It  is  much  better  to  adopt  Bigelow's  plan  (1878)  or  immediate  evacua- 
tion of  the  fragments  (litholapaxy) .  This  is  accomplished  by  gentle 
kneading  of  the  rubber  bulb  attached  to  the  evacuating  apparatus 
(Fig.  998),  which  procedure  creates  a  swirl  in  the  intravesical  fluid, 
as  a  result  of  which  some  fragments  are  drawn  into  the  bulb  at  each 


Fig.  998. — Bigelow's  evacuating  apparatus  withdrawing  fragments  of  calculus 
from  the  bladder.     (Watson  and  Cunningham.) 

motion,  and  by  the  force  of  gravity  fall  into  the  glass  receptacle 
immediately  beneath  the  rubber  bulb.  The  operation  of  litholapaxy  is 
not  now  in  general  use,  because  the  mortality  of  cutting  operations  is 
less  than  it  was  when  Bigelow's  operation  was  introduced,  and  because 
recurrence  of  stone  formation  is  frequent  (18  per  cent.),  either  because 
all  the  fragments  are  not  removed  at  first,  or  because  urinary  obstruc- 
tion and  vesical  infection  are  not  relieved.  But  the  primary  mortality 
is  very  low  (under  5  per  cent.),  and  the  operation  may  be  done  under 


VESICAL  CALCULUS  1025 

local  anesthesia  in  very  debilitated  subjects.     It  is  best  reserved  for 
such  patients,  provided  no  cystitis  is  present. 

Lithotomy. — Though  in  women  small  calculi  may  be  extracted  by 
dilating  the  urethra  (the  operation  is  termed  lithectasy) ,  in  the  large 
majority  of  cases  of  either  sex,  it  is  best  to  remove  calculi  by  an  incision 
into  the  bladder.  In  patients  under  fifty  years  of  age  the  primary 
mortality  is  low;  it  is  easy  to  ensure  the  removal  of  all  calculi,  efficient 
drainage  is  provided  when  necessary,  and  prostatic  obstruction,  if 
present,  may  be  treated  at  the  same  time.  Several  cutting  operations 
are  available,  but  the  suprapubic  route  is  the  operation  of  choice,  in 
either  sex  and  at  any  age. 


Fig.  999. — Instruments  used  in  lithotomy:   1.  Stone  searcher.  2.  Grooved  staff. 
3.  Lithotomy  forceps.  4.  Lithotomy  scoop  (probe  gorget  at  other  end). 

Suprapubic  Cystotomy. — This  may  be  done  under  local  anesthesia, 
but  in  children  a  general  anesthetic  is  preferable.  The  bladder  should 
be  distended  with  from  150  to  200  c.c.  of  saline  solution,  and  the 
patient  placed  in  the  Trendelenburg  position.  An  incision  of  5  to  8  cm. 
is  made  through  one  or  other  rectus  muscle,  close  to  the  median 
line  and  extending  right  down  to  the  pubis,  opening  the  space  of 
Retzius.  The  fingers  then  draw  upward  the  prevesical  fat  and 
fold  of  peritoneum.  The  bladder  is  recognized  by  its  bluish  color. 
Large  veins  should  be  avoided.  A  traction  suture  is  inserted  in 
the  bladder  wall  on  each  side  of  the  site  of  the  proposed  vesical 
incision,  and  the  bladder  is  then  opened  by  the  knife  which  cuts 
downward  toward  the  pubis.  Before  all  fluid  escapes  the  finger  is 
inserted  and  the  cavity  of  the  bladder  explored.  The  stone  is  then 
removed  with  suitable  forceps.  Be  careful  to  remove  all  the  stones 
and  not  to  overlook  one  in  a  diverticulum.  (If  indicated  the  prostate 
may  now  be  removed.  See  p.  1093.)  If  there  is  no  cystitis  (which  is 
seldom  the  case)  the  bladder  incision  may  be  closed  completely,  care- 
fully inverting  its  edges  so  as  to  prevent  prolapse  of  mucous  membrane. 
In  doubtful  cases  it  is  better  to  drain  by  inserting  a  tube  as  in  the  opera- 
tion of  cholecystostomy  (p.  985),  carefully  inverting  the  mucous  mem- 
brane. In  all  cases,  a  small  wick  of  rubber  tissue  should  be  placed  in 
the  space  of  Retzius.  The  vesical  tube  should  be  allowed  to  come  away 
of  itself,  which  it  usually  does  in  the  second  week.  The  urinary  fistula 
is  then  encouraged  to  close. 
65 


1026  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

Perineal  Lithotomy. — The  lateral  operation,  in  which  the  bladder  is 
opened  through  the  membranous  and  prostatic  urethra  by  an  incision 
which  passes  from  the  base  of  the  scrotum  outward  to  the  left  ischio- 
rectal fossa,  is  seldom  employed  now.  A  grooved  staff  (Fig.  999)  in 
the  urethra  is  used  as  a  guide  in  making  the  incision.  The  primary 
mortality  is  low,  especially  in  children,  but  the  deep  incision  is  apt 
to  injure  the  ejaculatory  ducts,  only  calculi  of  less  than  5  cm.  in 
diameter  can  be  removed,  and  it  requires  considerably  greater  skill 
than  the  suprapubic  operation.  Median  perineal  lithotomy  has  a  much 
higher  mortality,  and  affords  still  less  room. 

Foreign  Bodies. — Foreign  bodies  in  the  bladder  may  be  removed 
by  experts  with  the  operating  cystoscope.  In  the  hands  of  the  general 
surgeon  more  success  attends  suprapubic  cystotomy;  though  small 
objects  may  be  successfully  extracted  by  a  perineal  urethrotomy 
incision  (p.  1078). 

Injuries  of  the  Bladder  are  rare.  Most  frequent  are  ruptures. 
These  may  involve  the  intraperitoneal  or  the  extraperitoneal  surfaces, 
or  both.  They  occur  most  often  in  men,  and  the  chief  predisposing 
cause  is  alcoholic  intoxication:  this  increases  the  quantity  of  urine, 
obtunds  the  sensibilities  so  that  an  overloaded  bladder  is  neglected, 
and  renders  its  subjects  quarrelsome,  helpless,  and  prone  to  injury. 
The  chief  symptoms  are  abdominal  pain  and  bloody  anuria:  the  patient 
desires  to  urinate,  but  only  a  little  blood  is  passed.  Extraperitoneal 
rupture  frequently  complicates  a  fracture  of  the  pelvis,  and  is  diffi- 
cult to  distinguish  from  rupture  of  the  urethra  on  the  pelvic  side 
of  the  triangular  ligament  (see  p.  1072).  It  is  treated  by  supra- 
pubic drainage  of  the  bladder.  In  intraperitoneal  rupture  peri- 
tonitis soon  follows,  as  the  urine  seldom  is  aseptic.  The  diagnosis 
should  be  made  before  this  time  by  means  of  physical  examination. 
A  catheter  should  be  passed  (extreme  asepsis!)  and  any  bloody  urine 
present  should  be  evacuated.  Then  at  least  one  quart  (in  the  adult) 
of  sterile  saline  solution  should  be  injected,  unless  the  development 
of  a  suprapubic  mass  corresponding  to  the  unruptured  bladder  appears 
sooner.  Then  this  fluid  should  be  withdrawn.  Unless  all  the  injected 
fluid  is  regained,  it  is  evident  that  it  has  passed  out  of  the  bladder.  If 
more  fluid  than  was  injected  into  the  previously  emptied  bladder  is 
returned,  it.  is  evident  that  fluid  is  being  drained  from  the  peritoneal 
cavity.  In  either  case,  the  abdomen  should  be  opened,  the  rent  in 
the  bladder  sutured  (inverting  its  edges  with  sero-serous  sutures), 
and  the  peritoneal  cavity  drained.  It  is  also  well  to  leave  a  catheter 
in  the  bladder,  draining  it  through  the  urethra.  The  mortality  is 
about  23  per  cent.  (Ashhurst,  1906). 

SURGERY    OF    THE    KIDNEYS. 

Anomalies  of  Form  and  Position. — One  of  the  commonest  congenital 
malformations  of  the  kidney  is  the  so-called  horseshoe  kidney.  Here 
the  two  organs  are  fused  together,  usually  at  their  lower  poles.    This  is 


NEPHROPTOSIS  1027 

found  once  in  about  a  thousand  cases.  It  increases  the  difficulties  of 
diagnosis  and  treatment  of  kidney  lesions.  The  ureters  may  or  may 
not  be  normal  in  such  cases;  but  even  with  normal  kidneys  abnormali- 
ties of  the  ureters  are  not  very  rare.  The  commonest  abnormality  is 
the  existence  of  two  ureters  to  the  same  kidney;  each  may  spring  from 
a  separate  renal  pelvis,  or  both  may  leave  the  same  pelvis.  The  diag- 
nosis of  such  conditions  sometimes  is  made  before  operation  by  skiag- 
raphy after  catheterization  of  the  ureters  with  instruments  impervious 
to  the  a>ray  or  after  distending  them  with  collargol.  Anomalies  of  the 
blood-supply  of  the  kidneys  are  frequent.  The  most  important  are 
extra  arteries  to  the  upper  or  lower  pole  of  the  kidney,  or  an  artery 
which  crosses  in  front  of  the  ureter,  and  which  may  be  a  cause  of 
hydronephrosis  by  intermittent  pressure  or  by  causing  kinking  of  the 
ureter.  The  kidney  may  be  congenitally  misplaced  in  almost  any  posi- 
tion in  the  abdomen,  but  this  is  very  rare 

Nephroptosis,  or  Movable  Kidney  may  be  congenital  or  acquired 
(repeated  pregnancies,  tight  lacing),  is  more  common  in  women  than 
men,  and  on  the  right  than  the  left  side,  but  both  kidneys  often  are 
affected. 

Symptoms. — The  patients  usually  are  thin,  long-waisted,  run-down 
women  from  thirty  to  fifty  years  of  age.  In  most  cases  the  condition 
is  discovered  as  an  incident  in  an  abdominal  examination.  The 
chief  complaint  is  weakness  and  dragging  sensations  in  the  loin;  but 
acute  attacks  known  as  Dietl's  crises  (1864)  may  occur  from  torsion  of 
the  pedicle.  The  diagnosis  depends  on  recognizing  by  palpation  the 
movable  kidney.  Examination  is  conducted  with  the  patient  recum- 
bent, and  the  thighs  flexed  to  relax  the  abdominal  muscles.  The 
surgeon  places  one  hand  beneath  the  loin,  and  presses  downward 
firmly  but  gently  with  the  other  hand  in  the  flank,  until  the  two  hands 
are  approximated.  Then,  when  the  patient  takes  a  long  breath,  the 
lower  pole  of  the  kidney,  if  it  is  palpable,  is  forced  down  against  the 
examining  hand.  If  the  kidney  is  truly  movable  it  can  be  felt  also 
when  the  patient  stands  and  leans  forward,  resting  her  hands  on  the 
edge  of  the  bed.  The  examiner  now  stands  behind  her,  and  works 
his  hand  gently  upward  from  the  iliac  fossa  toward  the  flank;  where- 
upon, during  deep  inspiration,  a  movable  mass  may  be  recognized, 
which  slips  back  to  the  loin,  during  expiration.  A  floating  kidney 
can  almost  be  grasped  in  the  fingers,  and  may  be  found  in  the  iliac 
fossa  or  the  pelvis.  Fixation  of  such  a  floating  kidney  in  abnormal 
position,  by  adhesions  or  otherwise,  constitutes  a  dislocated  kidney. 
This  is  a  very  rare  condition.  A  Dietl's  crisis  is  recognized  by  its 
occurrence  in  a  patient  with  a  floating  or  movable  kidney,  by  the 
sudden  increase  in  size  of  the  tumor,  by  the  attending  constitutional 
disturbance  (nausea,  vomiting,  shock,  perhaps  chills  and  fever),  by 
the  absence  of  intestinal  or  peritoneal  symptoms,  and  by  prompt  sub- 
sidence of  symptoms  when  the  kidney  becomes  untwisted  on  lying 
down  or  by  manipulation.  Subsequently  microscopical  study  of  the 
urine  may  show  blood. 


1028  SURGERY  OF  THE  BLADDER  AND  KIDNEYS 

Treatment. — If  no  symptoms  exist,  no  treatment  is  indicated  beyond 
building  up  the  patient's  general  health.  If  symptoms  are  present 
they  often  are  relieved  by  a  rest-cure,  with  forced  feeding,  or  by  the 
application  of  an  abdominal  belt  such  as  was  advised  for  cases  of 
pendulous  abdomen.  It  rarely  is  desirable  to  use  a  special  pad  over 
the  kidney.  If  recurrent  attacks  of  torsion  occur,  or  if  palliative 
treatment  fails  to  relieve  chronic  symptoms  which  are  undoubtedly 
due  to  the  mobility  of  the  kidney,  this  organ  may  be  fixed  in  its  proper 
position  by  operation  (nephropexy).  Various  methods  are  employed. 
In  all  it  is  important  to  secure  the  kidney  in  a  position  as  nearly  normal 
as  possible,  avoiding  particularly  excessive  rotation  of  the  organ  in 
any  direction.  One  of  the  most  satisfactory  operations  is  to  incise 
the  capsule  along  the  convexity  of  the  kidney,  to  peel  the  capsule 
back  in  two  leaves,  and  to  suture  these  to  the  lumbar  aponeurosis 
(Edebohls,  1901).  The  lumbar  wound  is  closed  in  layers  without 
drainage. 

Infections  of  the  Kidneys  arise  in  most  cases  either  from  the  blood- 
stream or  as  ascending  infections  from  the  bladder  or  genitalia. 

Hematogenous  Infections. — The  kidneys  receive  from  the  body  and 
discharge  through  the  urine  great  quantities  of  toxins,  and  in  many 
cases  large  numbers  of  bacteria  (bacteriuria,  p.  1019).  If  the  resistive 
power  of  the  kidneys  is  weakened  (previous  renal  disease,  urinary 
obstruction,  trauma,  etc.)  or  if  the  toxins  or  bacteria  are  of  extra- 
ordinary virulence,  inflammation  of  the  kidneys  (nephritis)  results. 
There  are  various  forms  of  nephritis,  which  are  best  classed  as  acute 
and  chronic.    Only  some  of  these  need  concern  us  here. 

Cases  of  toxic  nephritis  due  to  mineral  poisons,  and  those  cases  due 
to  toxemia  (as  in  scarlatina,  diphtheria,  influenza,  etc.)  or  auto- 
intoxication (as  in  chronic  intestinal  stasis,  pregnancy,  etc.),  may  be 
acute  but  frequently  are  chronic  from  the  beginning,  and  usually 
are  cared  for  by  the  physician.  Of  late  years,  however,  it  has  become 
possible  to  relieve  some  of  these  patients  by  operative  means.  Punc- 
ture of  the  kidney  or  incision  of  its  capsule  was  advocated  by  R. 
Harrison  in  1897,  by  Ferguson  and  Edebohls  in  1899,  and  the  latter 
in  1901  reported  a  number  of  cases  in  which  he  had  practised  decap- 
sulation of  the  kidneys.  By  stripping  the  capsule  from  the  contracted 
and  sclerosed  kidney  its  nutrition  is  improved  by  relief  of  tension  and 
perhaps  by  development  of  collateral  circulation.  There  is  no  doubt 
that  in  many  cases  vast  improvement  occurs:  the  amount  of  the  urine 
increases,  the  edema  and  ascites  vanish,  casts  disappear  from  the 
urine,  and  previously  bed-ridden  patients  are  enabled  to  resume  a 
certain  degree  of  activity.  In  favorable  cases  this  improvement  has 
lasted  several  years,  though  evidences  of  chronic  nephritis  persist. 
In  other  patients,  however,  no  improvement  occurs  or  the  state  is  made 
worse.  The  operation  is  still  on  trial.  The  kidney  is  exposed  as  for 
other  kidney  operations  (p.  1040),  it  is  brought  into  the  wound,  and 
its  capsule  is  incised  along  the  convexity;  the  flaps  of  the  capsule  are 
then  stripped  off  the  organ  to  the  hilum  on  each  side,  and  are  excised; 


SEPTIC  NEPHRITIS  1029 

the  kidney  is  replaced  and  the  wound  closed  without  drainage,  but 
not  too  tightly.  It  is  better  to  postpone  operation  on  the  second 
kidney  for  a  week  or  ten  days.  Brewer  recommends  the  operation 
in  cases  of  severe  acute  nephritis,  following  the  exanthemas,  etc. 

Septic  Nephritis. — What  are  commonly  recognized  as  surgical 
infections  of  the  kidney,  of  hematogenous  origin,  are  cases  of  acute 
nephritis  due  to  septic  embolism.  In  a  large  proportion  of  cases  only 
one  kidney  (usually  the  right)  is  affected,  and  the  lesions  vary  from 
hemorrhagic  infarcts  (which  soon  heal,  leaving  minute  cicatrices) 
to  diffuse  suppuration.  Several  foci  of  suppuration  may  coalesce  and 
form  distinct  abscesses.  Extension  to  the  pelvis  of  the  kidney,  causing 
pyelitis,  is  frequent;  extension  to  the  fatty  capsule  of  the  kidney  and 
surrounding  structures  (perinephritis)  is  less  usual.  In  cases  where 
pelvis  and  kidney  are  diffusely  involved  (pyelo-nephritis)  it  may  be 
impossible  to  distinguish  the  pathological  changes  from  those  caused 
by  an  ascending  infection. 

Symptoms. — The  recognition  of  acute  unilateral  hematogenous  infec- 
tion of  the  kidney  is  due  mainly  to  the  work  of  Brewer  (1906.)  Over 
80  per  cent,  of  the  cases  occur  in  women,  frequently  as  a  sequel  of 
some  known  general  infection  (pneumonia,  tonsillitis,  furunculosis, 
etc.).  The  onset  and  course  of  the  disease  may  be  very  acute,  sub- 
acute, or  comparatively  mild.  The  severe  cases  usually  begin  with  a 
chill,  temperature  of  104°  or  105°  F.,  rapid  pulse  and  high  leukocytosis. 
From  the  first  the  symptoms  of  toxemia  are  marked,  and  the  local 
condition  may  be  overlooked,  the  disease  resembling  perhaps  influenza, 
lobar  pneumonia,  or  one  of  the  exanthemas.  Subsequently  attention 
is  directed  to  the  kidney  region  by  pain  and  discomfort  in  the  abdomen 
or  flank,  and  these  may  be  mistaken  for  signs  of  cholecystitis  or 
appendicitis.  Compensatory  action  of  the  healthy  kidney  may  obscure 
urinary  changes  (red-blood  cells,  albumin,  pus)  unless  especially  looked 
for.  "The  one  pathognomonic  sign  present  in  all  cases,"  adds  Brewer, 
"is  a  marked  unilateral  costovertebral  tenderness." 

Treatment. — In  the  severe  cases,  with  high  temperature  and  pro- 
gressive toxemia,  nephrectomy  should  be  done  without  unreasonable 
delay;  death  is  the  almost  invariable  result  of  such  delay  or  of  palliative 
operations.  In  the  milder  cases,  which  Brewer  describes  as  those 
where  the  temperature  begins  to  fall  within  forty-eight  hours,  decap- 
sulation of  the  kidney  may  be  done,  or  nephrotomy  if  there  is  evidence 
of  much  tension  or  localized  suppuration.  In  the  mildest  type,  where 
the  diagnosis  may  be  uncertain,  medical  treatment  may  be  persisted 
in,  and  any  chronic  pyelonephritis  which  remains  may  be  subjected 
to  appropriate  surgical  treatment  subsequently. 

Ascending  Infections. — Ascending  as  well  as  hematogenous  infection 
is  predisposed  to  by  previous  renal  disease  (especially  renal  calculus) 
or  the  occurrence  of  trauma;  but  even  in  such  circumstances  it  rarely 
occurs  unless  there  is  obstruction  to  the  urinary  outflow.  In  women, 
pressure  from  pelvic  tumors  or  the  gravid  uterus  is  a  cause  of  urinary 
obstruction  which  leads  not  infrequently  to  ascending  kidney  infec- 


1030  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

tion.  In  men  such  obstruction  is  due  in  most  instances  to  enlarge- 
ment of  the  prostate  or  stricture  of  the  urethra.  Back  pressure  of 
urine  within  the  bladder  first  compresses  the  ureteral  orifices,  damming 
the  urine  back  into  the  ureters  and  kidneys;  inflammatory  infiltration 
of  the  bladder  wall  from  cystitis  may  impair  the  sphincteric  action 
of  the  ureteral  orifices;  and  if  extreme  dilatation  of  the  bladder  occurs 
the  ureteral  orifices  may  become  constantly  patulous,  by  the  approxi- 
mation of  their  course  through  the  bladder-walls  to  a  straight  line. 
It  is  probable  also  that  infection  extends  up  the  walls  of  the  ureters 
to  the  kidney  pelvis,  and  thus  produces  pyelitis  and  pyelo-nephritis, 
which  are  the  usual  results  of  obstruction  in  the  presence  of  infection. 
In  some  cases  the  ureters  appear  unaffected,  but  in  most  they  are 
dilated,  pouched  and  perhaps  strictured.  The  pyelo-nephritis  arising 
from  ascending  infection  is  commonly  spoken  of  as  surgical  kidney. 
The  renal  cortex  is  thinned,  the  pelvis  enlarged,  and  the  kidney  sub- 
stance is  riddled  with  abscesses  of  various  sizes. 

Symptoms. — Surgical  kidney  is  more  frequent  in  the  aged  than  in 
the  young,  and  occurs  very  much  oftener  in  men  than  in  women. 
It  may  be  acute  or  chronic,  but  as  acute  attacks  tend  to  be  prolonged 
by  chronic  symptoms,  and  as  the  chronic  condition  frequently  is 
interrupted  by  acute  attacks,  the  symptomatology  is  best  considered 
together.  The  onset  usually  is  acute,  and  often  follows  exposure 
to  cold  or  wet,  the  passage  of  a  catheter,  sounding  for  stone,  or  dilata- 
tion of  a  urethral  stricture.  The  patient  has  a  chill,  is  nauseated,  his 
temperature  rises,  and  for  a  few  hours  he  may  be  very  ill.  In  many 
cases  these  symptoms  cannot  be  distinguished  from  those  of  so-called 
urethral  fever  (p.  1081),  but  the  diagnosis  of  pyelitis  is  probable  if 
fever  continues,  and  becomes  almost  a  certainty  if  there  is  a  dull  ache 
in  one  or  both  loins  and  if  an  enlarged,  tender  kidney  can  be  palpated. 
The  urine  contains  pus,  sometimes  blood,  and  usually  is  alkaline. 
The  pus  settles  slowly  to  the  bottom  of  the  receptacle,  whereas  the 
pus  of  cystitis  settles  very  quickly. 

One  or  both  kidneys  may  be  affected.  If  only  one  is  affected  and 
the  ureter  is  completely  blocked,  the  urine  may  be  fairly  normal,  while 
the  patient's  condition  will  grow  worse;  on  the  other  hand,  if  free 
drainage  of  the  kidney  is  present  the  patient  may  feel  quite  comfortable 
in  spite  of  the  infected  character  of  his  urine.  In  the  average  chronic 
case,  so  long  as  the  kidney  drains  freely,  the  patient  may  be  little 
troubled  by  subjective  symptoms  unless  an  exacerbation  occurs  from 
renewed  irritation  of  the  urinary  passages,  or  indiscretions  in  diet,  etc. 
Recurrence  of  acute  attacks  is  common,  as  the  kidney,  unlike  the 
bladder,  has  no  great  tendency  to  sterilize  itself  spontaneously. 

Treatment. — In  the  acute  cases  put  the  patient  to  bed,  and  ensure 
free  drainage  of  urine  from  the  bladder  by  an  inlying  catheter  if  neces- 
sary. Keep  the  patient  on  a  milk  diet,  and  make  him  drink  plenty 
of  water.  Give  one  gram  of  urotropin  three  times  daily.  Treat 
threatening  uremia  by  diuretics,  cathartics,  sweating,  and  if  necessary 
venesection.    If  the  urine  is  nearly  normal,  or  anuria  is  present,  and 


PERINEPHRIC  ABSCESS  1031 

the  kidney  enlarged  and  tender,  nephrotomy  or  rarely  nephrectomy 
may  be  required;  but  whenever  possible  radical  operation  should  be 
postponed  until  the  acute  attack  subsides.  When  the  chronic  stage 
is  reached,  radical  treatment  of  the  obstructing  cause  (stricture, 
enlarged  prostate,  etc.)  may  succeed  in  curing  the  pyelitis.  Before 
nephrectomy  is  done,  in  any  case,  the  functional  capacity  of  the  other 
kidney  must  be  proved  adequate  (p.  1016). 

Hydronephrosis. — This  is  hydrops  of  the  kidney  due  to  urinary 
obstruction,  in  the  absence  of  infection.  The  condition  may  be  unilat- 
eral or  bilateral.  Causes  of  unilateral  hydronephrosis  are  recurrent 
torsion  of  the  ureter  by  the  vagaries  of  a  movable  kidney;  impaction 
of  a  stone  in  the  ureter  without  complete  blocking  of  the  canal;  or 
stricture  of  the  ureter.  Bilateral  hydronephrosis  is  due  to  obstruction 
of  both  ureters,  either  directly,  as  by  a  tumor  of  the  bladder  involving 
both  ureteral  orifices,  pressure  of  a  pelvic  tumor,  etc.,  or  indirectly  by  en- 
largement of  the  prostate,  stricture  of  the  urethra,  etc.  The  symptoms 
occur  as  a  sequel  to  those  due  to  the  obstructing  lesion;  the  kidney 
becomes  enlarged  and  may  reach  an  immense  size.  If  temporary 
relief  of  the  obstruction  occurs,  the  accumulated  urine  is  discharged, 
with  polyuria  and  disappearance  of  the  tumor.  This,  however,  may 
soon  refill  {intermittent  hydronephrosis). 

Treatment. — Treatment  comprises  removal  of  the  obstruction  when 
this  is  possible.  A  movable  kidney  may  be  fixed;  a  stone  in  the  ureter 
removed;  a  stricture  of  the  ureter  treated  by  dilatation,  ureteroplasty 
(analogous  to  pyloroplasty)  or  by  resection  and  end-to-end  suture; 
a  pelvic  tumor  may  be  excised.  Finally,  if  no  obstruction  can  be 
found,  or  if  it  cannot  be  removed,  and  the  kidney  is  functionless, 
nephrectomy  may  be  done. 

Pyonephrosis. — Pyonephrosis  occurs  as  the  end-result  of  pyelo- 
nephritis, or  it  may  be  due  to  the  infection  of  a  preexisting  hydro- 
nephrosis. If  the  other  kidney  is  functionally  sufficient,  nephrectomy 
should  be  done.  Nephrotomy  with  drainage  rarely  is  beneficial,  and 
in  most  cases  nephrectomy  and  death  are  the  only  alternatives,  and 
death  may  follow  nephrectomy. 

Perinephric  Abscess. — This  is  suppuration  in  the  fatty  capsule  of 
the  kidney.  I  have  already  mentioned  the  occurrence  of  perineph- 
ritis as  a  sequel  of  septic  nephritis;  and  though  perinephritis  often 
results  in  suppuration  there  are  many  other  causes  for  perinephric 
abscess;  hence  the  term  perinephritic  abscess  should  not  be  used, 
the  kidney  being  at  fault  only  in  about  one-fifth  of  the  cases  (M.  B. 
Miller,  1909).  In  most  cases  the  source  of  infection  is  in  the  lower 
genito-urinary  tract,  and  extension  to  the  perirenal  tissues  occurs 
along  the  lymphatics.  Trauma  may  be  a  predisposing  cause.  Pul- 
monary complications  are  frequent. 

Symptoms. — Symptoms  often  are  subacute  in  onset,  and  the  patient 
may  not  be  laid  up  until  a  week  or  more  has  elapsed.  He  complains 
of  local  pain  and  tenderness,  walks  guardedly,  with  his  body  bent 
toward  the  affected  side;  and  the  hip  is  slightly  flexed;  there  is  local- 


L032  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

ized  muscular  rigidity,  and  a  tender  spot  between  the  twelfth  rib  and 
iliac  crest  posteriorly.  Later  there  may  be  moderate  or  high  elevation 
of  temperature;  leukocytosis  usually  is  high  (average  is  25,000) ;  and  still 
later  distinct  evidences  of  suppuration  develop.  Sometimes,  however, 
the  onset  is  very  acute,  with  chill,  high  fever,  and  extreme  prostration. 
The  diagnosis  is  not  always  easy,  even  if  the  condition  is  kept  in  mind. 
A  source  of  infection  should  be  looked  for.  Confusion  with  a  lumbar 
abscess,  due  to  Pott's  disease  of  the  spine,  should  not  arise  unless  such 
a  cold  abscess  is  secondarily  infected  and  signs  of  spinal  involvement 
are  absent. 

Treatment. — Treatment  consists  in  evacuating  the  abscess  by  a 
lumbar  incision;  and  this  should  not  be  postponed  if  the  symptoms 
are  acute,  even  if  the  diagnosis  is  uncertain. 

Nephrolithiasis  or  Renal  Calculus. — The  urine  of  many  persons 
may  contain  crystalloids  in  abnormal  amount,  yet  so  long  as  they  are 
held  in  solution  by  the  action  of  colloids,  no  stone  will  be  formed. 
If,  however,  the  crystalloids  are  present  in  excess  of  the  power  of  the 
colloids  to  hold  them  in  solution  by  means  of  what  is  known  as  adsorp- 
tion, then  the  crystalloids  (uric  acid,  acid  urates,  calcium  oxalate,  etc.) 
go  out  of  solution  and  are  deposited  on  the  colloids  as  a  matrix.  If 
the  colloids  are  what  are  known  as  reversible  colloids,  such  as  mucin, 
both  they  and  the  mineral  deposited  on  them  may  be  redissolved  by 
more  water.  If,  however,  the  colloid  is  irreversible,  such  as  fibrin, 
it  cannot  be  re-dissolved.  The  colloid  mostly  concerned  in  the  forma- 
tion of  urinary  calculi  is  believed  to  be  fibrin;  and  as  this  is  a  product 
of  inflammation  and  infection,  it  is  not  unreasonable  to  suppose  that 
calculi  may  form  as  the  remote  result  of  an  attenuated  infection  of 
the  urinary  tract,  much  as  gall-stones  are  formed  in  the  biliary  tract. 
But  the  influence  of  infection  in  these  cases  has  not  been  proved, 
and  it  is  customary  to  regard  such  calculi  (uric  acid,  oxalate  of  lime; 
rarely  cystin,  etc.)  as  primary  calculi,  in  contradistinction  to  those 
undoubtedly  the  result  of  bacterial  infection  of  the  urinary  tract, 
which  are  termed  secondary  calculi.  These  latter  usually  are  composed 
of  triple  phosphates  and  result  from  bacterial  decomposition  of  the 
urine.  Phosphatic  deposits  may  occur  as  laminations  on  primary 
calculi,  as  concretions  on  the  mucous  membrane  lining  the  urinary 
tract,  or  as  distinct  calculi. 

Renal  calculus  is  most  common  between  twenty  and  forty  years  of 
age,  affects  men  somewhat  oftener  than  women,  and  the  right  kidney 
a  little  oftener  than  the  left.  Both  kidneys  are  involved  in  from 
20  to  50  per  cent,  of  cases.  The  prevention  of  calculus  formation 
concerns  the  physicians;  when  stones  have  formed  in  the  kidney  the 
case  becomes  surgical. 

The  classification  of  urinary  concretions  as  sand,  gravel,  and  calculi, 
is  self-explanatory.  Sand  may  be  productive  of  no  definite  symptoms; 
gravel  gives  rise  to  repeated  attacks  of  renal  colic  as  the  small  stones 
pass  into  or  through  the  ureter;  while  a  calculus  so  large  as  to  be 
relatively  immovable  may  be  symptomless.     The  smaller  the  calculi, 


NEPHROLITHIASIS  1033 

as  a  general  rule,  the  greater  is  their  number  and  the  more  apt  are 
they  to  produce  symptoms. 

Symptoms. — These  may  be  divided  into  those  of  simple  nephro- 
lithiasis and  those  of  complications  of  the  disease,  such  as  renal  colic, 
hydronephrosis,  pyelitis,  and  its  sequels. 

In  simple  nephrolithiasis  (which  corresponds  to  simple  cholelithiasis) 
the  stones  remain  in  the  kidney  and  infection  is  absent.  There  may 
be  no  symptoms  to  call  attention  to  the  kidney.  What  symptoms  the 
patient  complains  of  usually  are  referred  to  the  bladder,  and  are  the 
effect  of  passage  of  urine  altered  in  quality  or  quantity.  Especially 
valuable  as  suggestive  of  renal  disorder  is  the  occurrence  of  blood  in  the 
urine,  usually  in  microscopic  amount.  It  may  be  present  only  after 
the  patient  has  been  up  and  about,  and  may  disappear  if  he  lies  quiet 
in  bed.  Unless  secondary  infection  occurs,  or  unless  the  kidney  is 
unduly  movable,  and  therefore  liable  to  congestion  or  to  hydro- 
nephrosis, it  is  unusual  for  much  pain  to  be  felt  in  the  kidney  region 


Fig.  1000. — Shadows  cast  in  a  radiogram  by  different  renal  calculi:  on  the  left,  phosphatic; 
in  the  centre,  uric  acid;  on  the  right,  oxalate  of  lime.     (Rothschild.) 

itself  or  for  macroscopical  hematuria  or  pyuria  to  occur.  But  sometimes 
complaint  is  made  of  a  dull  ache  in  the  lumbar  region,  and  quite 
frequently  there  is  tenderness  on  pressure  here,  or  over  the  lower  pole 
of  the  kidney  in  the  flank.  Sometimes  the  kidney  is  palpably  enlarged. 
Murphy  placed  special  reliance  on  fist  percussion  over  the  lower  ribs, 
using  one  hand  as  plessimeter  and  thumping  it  with  the  other  fist 
as  plessor.  He  claimed  that  in  the  presence  of  a  renal  calculus  this 
always  produces  severe  pain.  Subjective  symptoms,  such  as  pain 
over  the  kidney,  frequently  disappear  as  soon  as  the  patient  goes 
to  bed;  and  after  his  admission  to  a  hospital  ward  the  diagnosis  may 
seem  doubtful.  The  x-ray  is  of  inestimable  value  in  the  diagnosis  of 
renal  calculus,  but  unfortunately  it  may  be  difficult,  or  impossible,  to 
secure  a  skiagraph  which  will  show  calculi  of  pure  uric  acid  (Fig.  1000). 
Fortunately  few  calculi  are  composed  of  uric  acid  or  urates  without 
some  admixtures  of  other  salts.  No  plate  should  be  considered  satis- 
factory unless  the  shadow  of  the  psoas  muscle  is  clearly  visible.  Con- 
fusion arises  from  defects  in  the  plate,  shadows  of  fecal  concretions, 


Ili:;i  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

and,  in  the  case  of  ureteral  stone,  from  those  of  phleboliths,  calcifica- 
tion around  ligatures  left  at  previous  pelvic  operations,  etc.  The 
functional  capacity  of  the  other  kidney  (p.  1010)  should  be  ascertained 
in  every  case  of  renal  calculus. 

Renal  colic  is  the  most  frequent  symptom  of  complicated  cases  of 
nephrolithiasis,  but  it  may  be  caused  by  other  factors  than  the  passage 
of  a  calculus  through  the  ureter.  The  symptoms  are  the  same  as  in 
cases  of  Dietl's  crisis  (p.  1027),  but  in  the  latter  condition  the  kidney 


Fig.  1001. — Four  stones  in  left  kidney,  removed  at  operation.     Episcopal  Hospital. 

always  is  movable,  which  is  not  often  the  case  in  nephrolithiasis.  Pain 
is  referred  along  the  course  of  the  ureter,  into  the  testicle,  and  down 
the  thigh,  and  sometimes  to  the  end  of  the  penis.  The  pain  usually 
begins  and  ends  suddenly;  but  if  the  stone  is  impacted  in  the  ureter 
the  pain  ceases  gradually  and  light  attacks  of  colic  recur  often.  There 
may  be  nausea  and  vomiting,  but  there  seldom  is  much  constitutional 
disturbance,  unless  the  kidney  is  infected,  when  the  symptoms  of 
pyelitis,  etc.,  arise.  These  have  already  been  considered.  During 
the  continuance  of  the  colic  the  urine  may  be  diminished  or  entirely 


URETERAL  CALCULUS  1035 

suppressed;  crebruria,  with  tenesmus,  is  frequent,  and  blood  usually 
is  found  in  the  urine. 

Diagnosis  of  Nephrolithiasis. — This  is  not  certain  unless  the  stones 
are  seen  in  a  skiagraph  (Fig.  1001);  and  even  then,  as  noted  above, 
sources  of  error  are  not  infrequent.  If  gravel  has  been  passed,  and 
colic  persists,  it  is  a  fair  inference  that  other  stones  remain;  and  the 
diagnosis  is  very  probable  if  repeated  colic  occurs,  with  hematuria 
and  occasionally  pyuria,  with  symptoms  of  pyelitis.  The  chief  con- 
ditions from  which  renal  calculus  must  be  distinguished  are  biliary 
colic,  appendicitis,  and  intestinal  obstruction.  The  diagnosis  of  these 
has  already  been  considered. 

Treatment. — If  the  stones  are  shown  by  skiagraphy  to  be  merely 
gravel,  and  if  such  have  already  been  passed  successfully,  it  is  sometimes 
advisable  to  trust  to  medical  treatment  to  prevent  the  formation  of 
other  calculi,  and  to  allow  the  patient  to  pass  such  as  already  exist 
per  vias  naturales  (Fig.  1002).  Any  stone  too  large  to  be  passed 
requires  removal  by  operation ;  especially  is  this  true  when  pyelitis  is 
present  and  fails  to  clear  up  under  palliative  treatment. 


Fig.  1002. — Renal  calculus  of  uric  acid  passed  by  urethra.     (Scale  in  inches.) 
Orthopaedic  Hospital. 

If  the  stones  lie  loose  in  the  kidney  pelvis,  a  fact  which  cannot  be 
determined  before  the  kidney  is  exposed,  they  should  be  removed  by 
pyelotomy;  if  they  are  fixed  in  the  cortex,  nephrotomy  (nephrolith- 
otomy) should  be  done.  These  operations  are  described  at  p.  1041.  If 
the  presence  of  calculi  is  uncertain  it  is  better  to  incise  the  kidney 
sufficiently  to  explore  its  interior  than  to  endeavor  to  locate  the  stone 
by  "needling"  the  kidney.  In  all  cases  a  sound  or  ureteral  catheter 
should  be  passed  down  the  ureter  to  the  bladder,  to  make  certain 
that  no  obstruction  has  been  overlooked. 

Ureteral  Calculus. — The  .r-ray  has  shown  that  calculus  is  more 
frequent  in  the  ureter  than  in  the  kidney  (C.  L.  Leonard).  In  nearly 
all  cases  the  stone  has  descended  from  the  kidney.  It  lodges  by  pref- 
erence (1)  just  below  the  renal  pelvis;  (2)  at  the  brim  of  the  true  pelvis; 
or  (3)  just  outside  the  bladder  wall.  Blockage  of  the  ureter  in  the 
first  position  causes  symptoms  similar  to  those  of  renal  calculus;  in 
the  last  position,  those  resembling  cystitis.  Stones  arrested  at  the 
brim  of  the  pelvis  frequently  are  mistaken  for  chronic  appendicitis, 
and  the  appendix  is  removed  in  vain. 

Complete  blockage  of  the  ureter  may  bring  on  calculous  anuria. 
This  may  be  due  to  the  functionally  useless  state  of  the  second  kidney; 
to  blockage  of  both  ureters  at  once;  to  the  existence  of  only  one  kidney, 


1030  SURGERY  OF  THE  BLADDER  AND  KIDNEYS 

or  of  a  horseshoe  kidney  with  a  single  ureter;  or  to  what  is  called 
"reflex  inhibition"  of  the  healthy  kidney.  Unless  relieved  by  opera- 
tion, calculous  anuria  usually  terminates  in  uremia  and  death;  occa- 
sionally death  occurs  suddenly  without  uremic  symptoms.  The  free 
interval  varies  from  one  to  sixteen  days,  but  rarely  is  it  longer  than 
three  or  four  days. 

Treatment. — A  stone  in  the  upper  part  of  the  ureter  often  can  be 
worked  backward  into  the  kidney  pelvis;  if  not,  it  must  be  exposed 
by  enlarging  the  lumbar  wound,  and  removed  by  direct  incision  of  the 
ureter  (ureterolithotomy).  If  in  the  middle  portion  of  the  ureter, 
the  stone  is  best  exposed  extraperitoneally  through  a  McBurney  or 
similar  incision.  As  the  peritoneum  is  stripped  up  from  the  iliac  fossa, 
it  carries  the  ureter  with  it.  Gibbon  (1908)  placed  a  finger  inside  the 
peritoneal  cavity  to  aid  in  bringing  the  ureter  into  the  wound.  A 
stone  very  near  the  bladder  may  be  reached  extraperitoneally  by  the 
suprapubic  route  (C.  L.  Gibson,  1910);  vaginal  and  perineal  opera- 
tions are  less  satisfactory.  A  calculus  in  the  intramural  part  of  the 
ureter  may  be  extracted  by  suprapubic  cystotomy,  or  even  by  means 
of  the  operating  cystoscope. 

Calculous  anuria  requires  active  treatment  to  prevent  uremia;  hot 
baths,  sweating  (pilocarpin) ;  morphin  and  atropin  to  allay  pain  and 
spasm.  Unless  the  anuria  is  relieved  within  thirty-six  or  at  the  most 
forty-eight  hours,  operation  should  be  done.  There  is  no  time  to 
undertake  an  elaborate  search  for  the  site  of  obstruction  in  the  ureter; 
so  unless  this  is  known  (when  ureterolithotomy  by  the  proper  route 
is  indicated)  the  diseased  kidney  should  be  incised  and  drained,  the 
radical  operation  being  postponed  until  convalescence. 

Tuberculosis  of  the  Kidney. — Tuberculosis  of  the  genito-urinary 
tract  usually  develops  first  in  the  kidney  (66  per  cent,  of  cases),  or  the 
epididymis  (30  per  cent.) ;  in  a  few  cases  it  appears  first  in  the  Fallopian 
tubes,  the  prostate,  testis,  uterus  or  seminal  vesicles  (Watson  and 
Cunningham).  In  nearly  all  cases  the  infection  is  blood-borne  and 
is  secondary  to  a  focus  elsewhere  in  the  body  (bronchial  or  mesenteric 
lymph  nodes).  The  bladder,  as  pointed  out  at  p.  10.10,  scarcely  ever 
is  the  first  portion  of  the  genito-urinary  tract  to  be  invaded,  and  as  a 
consequence  ascending  tuberculous  infection  of  the  kidney  is  exceed- 
ingly rare.  Secondary  pyogenic  infection,  however,  frequently  ascends 
from  the  bladder  and  causes  rapid  disintegration  of  the  tuberculous 
kidney. 

In  most  cases  only  one  kidney  (the  right  and  left  about  equally) 
is  affected  at  first,  and  the  other  kidney  may  remain  intact  for  a  long 
time.  The  lesions  commence  in  the  cortex,  but  the  pelvis  is  invaded 
when  rupture  of  the  caseous  foci  occurs.  The  ureter  may  remain 
healthy  long  after  the  infection  has  secured  a  foothold  in  the  bladder. 

The  disease  is  most  frequent  in  early  adult  life,  and  the  sexes  are 
about  equally  affected.  At  the  time  patients  come  to  operation  the 
disease  is  still  confined  to  one  kidney  in  more  than  half  the  cases, 


TUBERCULOSIS  OF   THE  KIDNEY  1037 

and  even  at  autopsy  the  second  kidney  is  free  in  about  one  out  of 
three  cases.  In  the  large  majority  of  cases  of  bilateral  disease  the 
second  kidney  is  only  very  slightly  involved. 

Symptoms. — There  are  both  constitutional  symptoms  characteristic  of 
a  tuberculous  lesion,  and  local  symptoms  referable  to  the  urinary  tract. 
Among  the  former  may  be  mentioned  afternoon  pyrexia,  nervousness, 
sleeplessness,  anorexia,  and  loss  of  weight.  Though  the  patient  seems 
ill,  no  definite  cause  is  apparent.  After  weeks  or  months,  urinary 
symptoms  appear.  At  first  these  are  referred  to  the  bladder; 
the  urine  is  passed  frequently;  its  quantity  is  increased,  and  its 
specific  gravity  lessened ;  it  contains  pus  and  microscopical  amounts  of 
blood.  Frank  hematuria  is  rare.  Vesical  irritability  may  be  extreme 
before  the  tuberculous  lesion  has  spread  to  the  bladder.  Secondary 
pyogenic  infection  of  the  kidney  causes  hectic  fever,  night  sweats, 
emaciation,  and  rapid  loss  of  strength.  Not  until  this  stage  is  reached 
is  the  acidity  of  the  urine  lost. 

Diagnosis. — Vesical  symptoms  should  not  divert  attention  from  the 
kidney.  Pus  in  the  urine  does  not  necessarily  mean  cystitis.  In  cys- 
titis the  urine  almost  always  is  alkaline;  but  in  renal  tuberculosis  it 
remains  acid  until  pyogenic  infection  is  far  advanced.  Occurrence 
of  remissions  in  the  severity  of  the  symptoms  is  highly  characteristic 
of  tuberculosis,  but  is  unusual  in  renal  calculus.  In  the  latter,  exacer- 
bation of  symptoms  usually  follows  exercise;  but  in  renal  tuberculosis 
this  constant  relation  of  cause  and  effect  is  not  seen.  Renal  calculus 
usually  may  be  excluded  by  skiagraphy.  In  tuberculosis  the  tempera- 
ture chart  (even  in  the  absence  of  pyogenic  infection)  should  rouse 
suspicion  of  the  nature  of  the  infection.  The  hypodermic  use  of  tuber- 
culin and  inoculation  experiments  with  the  centrifugated  urinary 
sediment,  are  valuable  aids  in  diagnosis.  Cystoscopy  usually  reveals 
appearances  around  the  ureteral  orifice  on  the  diseased  side  which 
are  considered  by  experts  highly  characteristic.  Ureteral  catheteri- 
zation is  the  surest  way  of  determining  the  healthy  condition  of 
the  second  kidney.  In  many  cases  inoculations  and  examinations 
of  the  urine  for  tubercle  bacilli  have  to  be  repeated  on  several 
occasions,  as  the  results  are  not  always  constant. 

Treatment. — Most  surgeons  are  in  accord  in  recommending  removal 
of  the  diseased  kidney  as  the  only  hope  of  cure;  even  if  the  other  kidney 
is  slightly  diseased,  the  tuberculous  process  may  become  latent  in  it 
after  the  more  diseased  organ  has  been  removed.  The  excellent  effect 
of  nephrectomy  on  vesical  tuberculosis  has  already  been  mentioned 
(p.  1020).  The  immediate  mortality  of  nephrectomy  for  tuberculosis 
is  from  5  to  10  per  cent.;  and  about  26  per  cent,  of  patients  are  cured 
of  the  disease  and  remain  well  for  three  years  or  longer.  In  most 
others  great  improvement  occurs.  But  if  the  second  kidney  is  incom- 
petent, nephrectomy  should  not  be  done,  and  hygienic  treatment  alone 
must  be  employed.  If  pyonephrosis  is  present,  relief  may  be  afforded 
by  nephrotomy  and  drainage,  if  nephrectomy  is  contraindicated. 


1038  SURGERY  OF  THE  BLADDER  AND  KIDNEYS 

Tumors  of  the  Kidney. — These  are  conveniently  classed  as  solid 
tumors  and  cysts. 

Solid  Tumors  of  the  Kidney. —  Hypernephroma  is  the  commonest 
(p.  129).  Other  solid  tumors  are  sarcoma  and  carcinoma.  Benign 
solid  tumors  are  very  rare.  Solid  tumors  occur  oftenest  in  adult  life, 
especially  from  forty  to  sixty  years  of  age;  but  sarcomas,  embryonic 
tumors  and  tumors  of  the  adrenal  gland  are  seen  in  children. 

The  physical  signs  of  all  these  solid  tumors  are  much  the  same, 
and  have  been  considered  under  the  differential  diagnosis  of  enlarge- 
ments of  the  spleen  (p.  1007).  Hypernephroma  may  grow  to  immense 
size,  but  the  other  malignant  tumors  kill  before  they  reach  great  size. 
Symptomatic  varicocele  and  severe  referred  pain  are  usual  results,  and 
ascites  is  an  unusual  result  of  pressure  by  kidney  tumors.  The  chief 
characteristic,  apart  from  the  presence  of  a  tumor,  is  hematuria,  which 
often  is  painless,  usually  is  profuse,  and  occurs  without  vesical  symp- 
toms. Bright  red  blood  is  passed  from  the  urethra  when  the  patient  ex- 
pects urine.  Bleeding  may  be  so  profuse  as  to  produce  faintness,  recurs 
at  irregular  intervals,  and  is  not  made  worse  by  exercise  as  is  the  less 
marked  bleeding  which  attends  renal  calculus.  If  the  ureter  is  blocked 
by  a  clot  the  urine  is  clear,  but  diminished  in  amount,  and  severe  pain 
may  be  felt  in  the  loin.  When  hemorrhage  occurs  and  back  pressure 
on  the  kidney  is  relieved  the  patient  may  feel  better.  Tumor  of  the 
adrenal  sometimes  may  be  distinguished  from  tumors  of  the  kidney 
proper  by  attention  to  certain  details:  it  is  most  frequent  in  children, 
and  anorexia,  listlessness,  loss  of  weight  and  strength  may  be  noted 
weeks  or  months  before  the  tumor  is  discovered;  the  tumor  grows 
beneath  the  diaphragm,  pushes  the  kidney  down,  causes  early  referred 
pain  and  paresthesia,  and  sometimes  is  accompanied  by  bronzing  of 
the  skin  and  precocious  puberty;  hematuria  is  very  rare.  The  skeleton 
always  should  be  examined  for  metastases.  According  to  Symmers 
(1917),  when  the  adrenal  medulla  is  the  seat  of  tumor  formation  in 
children  (neuroblastoma;  ganglioneuroma,  p.  129)  two  distinct  clinical 
types  are  recognizable:  (1)  Extensive  metastases  in  cranium  and 
regional  lymph  nodes  attended  by  secondary  exophthalmos  and  ecchy- 
mosis  of  lids;  and  (2)  rapidly  increasing  distention  of  abdomen  due 
to  neoplastic  infiltration  of  the  liver,  without  ascites  or  jaundice. 

Prognosis. — Hypernephroma  generally  leads  to  death  within  three 
or  four  years.  Sarcoma  and  carcinoma  terminate  fatally  within  a 
year  or  less,  as  do  tumors  of  the  adrenal  in  children. 

Treatment. — Nephrectomy  should  be  done  whenever  possible. 
If  the  growth  is  large  the  transperitoneal  route  is  the  best.  The 
immediate  mortality  of  operation  is  about  25  per  cent,  and  most 
patients  who  survive  succumb  to  metastases  within  two  years. 

Cystic  Tumors  of  the  Kidney  are  rare  and  of  little  surgical  interest. 
Polycystic  disease  sometimes  appears  to  be  hereditary;  it  is  seen 
oftenest  in  early  infancy  or  in  middle  life  and  may  be  due  to  lack  of 
proper  fusion  of  the  cortical  with  the  pelvic  portions  of  the  kidney  in 
the  embryo;  usually  both  kidneys  are  affected,  and  hence  nephrec- 


OPERATIONS  ON  THE  KIDNEY 


1039 


tomy  which  otherwise  would  be  proper,  is  contra-indicated.  Simple 
serous  cysts  of  the  kidney  also  occur,  but  are  exceedingly  rare. 

Injuries  of  the  Kidney. — Rupture  from  falls,  kicks,  etc.,  is  more 
frequent  than  stab  or  gunshot  wounds.     The  latter  are  recognized 
by  the  course  of  the  missile,  bleeding  into  the  bladder,  and  sometimes 
the  discharge  of  urine  from  the  wound, 
Subcutaneous  injury  varies  from  con- 
tusion, to  fragmentation,  or  complete 
disruption  (pulpefaction)   of  the  kid- 
ney.   There  is  hematuria,  and  in  most 
cases  a  hematoma  forms  in  the  flank. 
Intraperitoneal    hemorrhage    is  rare. 
There  is  much  local  pain  and  tender- 
ness, and  if  bleeding  is  profuse  or  long 
continued  even  in  small  amount  the 
usual  consequences  ensue. 

Treatment. — In  cases  of  gunshot  or 
stab  wound  the  kidney  should  be 
exposed  and  the  wound  tamponed 
or  closed  by  suture.  There  is  little 
prospect  of  spontaneous  arrest  of 
hemorrhage.  In  subcutaneous  in- 
juries, on  the  other  hand,  bleeding 
frequently  ceases  when  the  patient 
is  kept  quiet  in  bed,  with  ice  locally 
and  morphin  internally.  Salol  or  uro- 
tropin  should  be  given.    If  bleeding 

is  very  profuse,  and  particularly  if  the  lumbar  hematoma  continues 
to  increase  in  size,  the  kidney  should  be  exposed  and  its  wound 
tamponed,  or,  better,  closed  with  mattress  sutures  of  chromic  gut, 
deeply  inserted  and  including  the  fibrous  capsule.  Nephrectomy  is  to 
be  avoided;  even  a  portion  of  the  kidney  completely  detached  may 
be  sutured  in  place  (Fig.  1003),  and  if  even  only  one-tenth  of  what 
is  saved  retains  its  functional  activity,  the  patient  is  just  so  much 
better  off  than  if  it  had  been  removed. 


Fig.  1003. — Rupture  of  right  kidney 
(anterior  view).  Woman,  aged  thirty- 
two  years,  fell,  striking  loin  on  a  step. 
Operation  for  increasing  hematoma 
four  hours  after  injury.  Fragment 
sutured  to  kidney.  Recovery.  Epis- 
copal Hospital. 


OPERATIONS  ON  THE  KIDNEY. 


Position  of  the  Patient. — In  lumbar  operations  the  patient  should 
lie  prone,  with  a  sand-bag  or  other  support  between  the  costal  margin 
and  pelvis.  When  the  kidney  has  been  exposed  the  patient  may  be 
drawn  toward  the  foot  of  the  table,  while  the  sand-bag  is  kept  immov- 
able. Thus  it  compresses  the  lower  thorax,  enforces  abdominal  breath- 
ing, and  the  kidney  tends  to  prolapse  into  the  wound  (Edebohls). 
In  the  abdominal  approach  the  position  is  similar  to  that  employed 
in  operations  on  the  bile-ducts,  but  with  the  patient  turned  a  little 
toward  the  healthy  side. 


1(110 


SURGERY  OF   THE  BLADDER  AND  KIDNEYS 


Incisions. — The  usual  incision  for  haiibar  operations  runs  parallel 
to  the  last  rib,  and  about  2  cm.  below  it,  from  the  outer  border  of  the 

erector  spinas  mass  for  10  to  15  cm. 
downward  and  forward.  This  incision 
may  be  extended  forward  in  the  course 
of  the  motor  nerves  of  the  abdominal 
wall  (Fig.  1004).  The  iliohypogastric 
and  ilioinguinal  nerves  lie  just  below 
this  incision  between  the  transversalis 
fascia  and  the  oblique  muscles,  and 
should  not  be  injured.  If  more  room  is 
desired  at  the  upper  angle  of  the  wound, 
the  lateral  arcuate  ligament,  which  binds 
the  twelfth  rib  to  the  transverse  process 
of  the  first  lumbar  vertebra,  and  the 
quadratus  lumborum  may  be  cut  and 
the  rib  thus  mobilized.  By  keeping 
close  to  the  rib  there  is  not  much 
danger  of  wounding  the  pleura.  This 
oblique  incision  divides,  at  the  spinal 
end,  the  latissimus  dorsi;  at  the  ab- 
dominal end,  the  oblique  abdominal 
muscles  at  their  origin  from  the  lumbar 
aponeurosis.  This  aponeurosis  itself  is 
divided  as  far  backward  as  the  erector 
spinas  mass.  Then  the  transversalis  fascia  is  divided.  These  struc- 
tures are  shown  diagrammatically  in  Fig.  1005.  When  they  have 
been  incised  the  peri-renal  fat,  enclosed  in  the  fascia  of  Gerota,  is 


Fig.  1004. — Incision  for  exposure  of 
kidney  by  lumbar  route. 


Fig.  1005. — Cross-section  of  left  lumbar  region,  to  show  structures  concerned  in 
operations  on  the  kidney  (diagrammatic).  1.  External  oblique  muscle.  2.  Internal 
oblique  and  transversalis  muscles.  3.  Latissimus  dorsi.  4.  Lumbar  aponeurosis.  5. 
Perirenal  fascia.     6.  Peritoneum.     7.   Ureter.     8.  Renal  artery.     9.  Renal  vein. 


exposed.  In  infected  cases  this  fatty  capsule  may  be  dense,  but  usually 
it  is  easily  displaced  by  the  finger,  exposing  the  kidney  covered  by  its 
true  capsule. 


OPERATIONS  ON  THE  KIDNEY  1041 

In  exposure  of  the  kidney  by  the  abdominal  route,  the  best  incision 
is  one  parallel  to  the  motor  nerves,  beginning  at  the  semilunar  line 
at  the  level  of  the  umbilicus  and  running  back  toward  the  flank  as 
far  as  necessary. 

Nephrotomy. — After  exposure  of  the  kidney  by  a  lumbar  incision, 
as  indicated  above,  proceed  to  enucleate  it  from  its  fatty  capsule. 
Free  both  poles  as  well  as  the  anterior  and  posterior  surfaces  by  blunt 
dissection  with  the  finger,  and  do  not  attempt  to  deliver  the  kidney 
into  the  wound  until  it  has  been  thoroughly  freed.  In  infected  cases  it 
may  be  impossible  to  free  the  kidney,  on  account  of  adhesions;  hemor- 
rhage may  then  be  controlled  by  clamping  the  pedicle  with  rubber- 


Fig.  1006. — Nephrotomy:  The  kidney  drawn  out  on  the  back  and  its  pedicle  com- 
pressed with  the  fingers.  The  splitting  of  the  kidney  here  shown  illustrates  the  operation 
for  removal  of  stones  from  the  calices.     (Watson  and  Cunningham.) 

covered  forceps  while  the  kidney  is  opened.  If  the  kidney  can  be 
delivered,  deliver  the  upper  pole  first  and  control  the  pedicle  between 
the  fingers  (Fig.  1006).  Incise  it  longitudinally  a  little  posterior  to  the 
convex  border,  in  the  bloodless  zone,  so  as  to  avoid  Brodel's  white 
line  which  overlies  the  principal  vessels  supplying  the  renal  cortex. 
Brewer  opens  the  exposed  kidney  by  Hilton's  method  (p.  50),  so  as 
to  avoid  hemorrhage. 

If  the  operation  is  for  the  removal  of  calculi   (nephrolithotomy) 
a  largejcortical  incision  is  desirable,  so  as  to  expose  all  the  calices 
and  thejpelvis  and  allow  probing  of  the  ureter.     If  the  operation  is 
66 


1042 


SURGERY  OF   THE   BLADDER  AND  KIDNEYS 


done  merely  for  drainage,  the  opening  need  not  be  s<>  large.     At   the 
conclusion  of  the  operation,  bleeding  is  arrested  by  mattress  sutures 
of  chromic  gut  through  the  kidney. 
The  lumbar  wound  should  be  drained  in  all  eases. 


Fig.  1007. — Nephrectomy:  Manner  of  clamping  and  tying  the  pedicle  of  the 
kidney.      (Watson  and  Cunningham.) 

If  the  stones  are  known  to  lie  in  the  kidney  pelvis,  pyelotomy  should 
be  preferred  to  nephrolithotomy.  The  pelvis  is  exposed  by  turning 
the  kidney  forward  and  clearing  off  by  gentle  blunt  dissection  the  fat 
which  covers  the  posterior  surface  of  the  kidney  pelvis.  The  pelvis 
is  then  incised  a  short  distance  from  the  kidney.  After  removal  of 
calculi  and  probing  of  the  ureter,  the  fatty  tissue  overlying  the  pelvis 
is  sutured  back  in  place,  as  this  tends  to  prevent  leakage.  Drainage 
should  be  by  rubber  tissue,  not  by  gauze. 


OPERATIONS  ON  THE  KIDNEY  1043 

Nephropexy  has  been  sufficiently  described  (p.  1028). 

Nephrectomy. — The  kidney  is  exposed,  and,  if  possible,  is  delivered 
through  the  wound.  The  pedicle  is  attacked  from  below.  Clamp 
the  proximal  and  ligate  the  distal  portion  of  the  ureter,  cut  between, 
and  leave  the  ligature  long.  Expose  the  renal  arteries  and  vein  by 
blunt  dissection,  from  the  front  of  the  kidney;  if  not  too  bulky,  ligate 
the  pedicle  en  masse,  or  transfix  and  tie  on  both  sides.  Leave  the  liga- 
ture long.  Then  catch  the  pedicle  between  the  kidney  and  the  ligature 
in  forceps,  and  cut  between  the  kidney  and  the  forceps,  removing  the 
kidney,  but  leaving  the  forceps  on  the  pedicle.  In  case  bleeding 
occurs  (it  may  be  profuse)  the  pedicle  can  be  drawn  into  the  wound, 
and  another  ligature  applied.  If  it  is  impossible  to  expose  the  pedicle 
satisfactorily,  it  may  be  clamped  and  the  kidney  cut  away.  Never 
tie  the  ligature  while  the  clamp  is  in  place,  since  when  the  clamp  is 
released  and  the  pedicle  retracts  the  ligature  may  be  forced  off.  It 
is  permissible  to  hold  the  pedicle  in  a  clamp  while  the  ligature  is  being 
passed  (Fig.  1007),  but  before  the  ligature  is  tied  the  clamp  must  be 
released.  If  this  is  impossible,  the  clamp  must  be  left  in  place  for 
four  or  five  days. 

The  kidney  being  removed  and  all  hemorrhage  checked,  the  liga- 
ture on  the  ureter  is  pulled  upon,  and  the  ureter  drawn  into  the  wound. 
As  much  as  possible  of  it  should  be  resected,  and  the  end  securely 
ligated.  In  septic  or  tuberculous  cases  it  is  well  to  inject  10  drops 
of  carbolic  acid,  thus  ensuring  obliteration  of  its  lumen.  In  all  cases 
temporary  drainage  of  the  wound  is  essential. 

Closure  of  the  Wound. — In  all  operations  on  the  kidney,  whether 
drainage  is  employed  or  not,  the  same  care  in  suturing  the  wound 
should  be  taken  as  in  abdominal  operations.  Hernia  is  not  very 
infrequent  if  suturing  is  carelessly  done. 


CHAPTER  XXVI. 
VENEREAL  DISEASES. 


SYPHILIS. 

The  pathology  of  syphilis  is  discussed  in  Chapter  III. 
Contagion. — The  disease  may  be  inherited  (congenital  syphilis)  as 
well  as  acquired.  The  only  pathological  difference  between  these  two 
forms  of  the  disease  is  that  in  the  inherited  form  there  is  no  primary 
lesion  (chancre),  the  infecting  organism  having  entered  the  infant's 
body  through  its  mother's  blood  or  with  the  semen  of  the  father.1 
The  lesions  of  syphilis  from  which  the  disease  may  be  contracted  are 
the  primary  lesion  (chancre),  and  the  secondary  lesions  (especially 
mucous  patches).  Tertiary  lesions  seldom  if  ever  convey  the  con- 
tagion. In  nearly  all  cases  there  is  at  the  point  of  inoculation  a  pre- 
existing abrasion,  crack,  or  fissure 
in  the  epithelium  of  the  patient 
inoculated;  inoculation  through 
the  intact  skin  is  very  rare. 

The  occurrence  of  immediate  and 
mediate  contagion  was  also  men- 
tioned in  discussing  the  pathology 
of  syphilis.  In  most  cases  syphilis 
is  acquired  by  immediate  con- 
tagion, during  sexual  intercourse. 
Hence  it  is  classed  as  a  venereal 
disease.2  The  sores  from  which  the 
virus  is  derived  being  situated  on 
the  genitalia,  the  sore  produced  by 
inoculation  likewise  develops  on  the 
genitals.  If  the  disease  is  not  con- 
tracted during  coitus,  the  primary  lesion  usually  is  not  on  the  genitalia 
(though  it  may  be),  but  on  the  lip  (Fig.  1008),  face  or  other  exposed 
portion  of  the  body;  and  is  due  to  direct  contact  with  contagious 
sores  in  another  individual  (immediate  contagion)  or  to  mediate 
contagion  through  infected  towels,  eating  and  drinking  utensils,  etc. 
Such  patients  being  regarded  as  innocent,  the  disease  in  them  is  some- 
times termed  syphilis  insontium.  In  such  cases  mediate  contagion 
may  conceivably  cause  inoculation  in  the  genitalia;  but  the  presump- 

1  It  has  not  been  found  possible  to  produce  a  similar  form  of  the  disease  experi- 
mentally (using  monkeys),  since  the  treponema  is  destroyed  by  phagocytosis 
when  injected  directly  into  the  blood.  According  to  Levaditi  and  Roche,  however, 
syphilis  without  any  primary  lesion  has  been  produced  by  injecting  the  organisms 
into  the  testicle  where  they  are  able  to  develop.  In  these  cases  the  first  manifes- 
tations of  the  disease  corresponded  to  secondary  syphilis,  and  in  so  far  resembled 
the  congenital  form. 

2  Until  Ricord,  in  1836,  pointed  out  the  clinical  differences  between  chancre  and 
gonorrhea,  these  two  affections  were  not  distinguished,  both,  as  well  as  chancroid, 
being  considered  lesions  of  "the  venereal  disease"  (syphilis). 

(1044) 


Fig.  1008. — Chancre  of  the  lip ;  duration 
three  weeks.  Age,  eighteen  years.  Devel- 
oped two  weeks  after  exposure.  Dr. 
Alexander's  patient.     Episcopal  Hospital. 


SYPHILIS 


1045 


Fig.  1009. — Multiple  chancres  (penis  and 
abdomen),  the  result  of  simultaneous  inocula- 
tion.    Episcopal  Hospital. 


tion  is  strong  that  a  genital  sore  has  been  acquired  during  the  venereal 
act.  Yet  it  is  well  to  remember  that  such  occurrences  are  at  least 
possible,  and  care  should  be  taken  not  to  wound  the  feelings  of  others 
and  perhaps  cause  domestic  unhappiness  by  expressing  an  unguarded 
opinion,  which,  after  all,  may  prove  erroneous  (J.  Ashhurst,  Jr.). 

Symptoms  and  Diagnosis  of  Chancre. — A  chancre  develops  from 
three  to  five  weeks  after  exposure,  and  occurs  first  as  a  reddish-brown 
papule;  but  usually  when  first  seen  exfoliation  of  the  overlying  epithe- 
lium has  occurred.  The  chancre 
appears  as  a  superficial  erosion, 
which  is  common,  or  as  a  deep 
excavated  ulcer  (Hunterian 
chancre),  which  is  rare. 

In  the  male,  chancre  usually 
develops  on  the  prepuce,  fre- 
num,  or  glans  penis;  less  often 
on  the  body  of  the  penis,  the 
abdomen,  or  elsewhere.  In  the 
female  it  occurs  on  the  labia, 
within  the  vagina,  or  on  the  cer- 
vix uteri;  occasionally  around 
the  anus  or  in  the  perineum. 
In  men  it  usually  attracts  at- 
tention as  soon  as  it  develops, 
on  account  of  its  exposed  posi- 
tion; in  women,  for  the  contrary  reason,  it  is  generally  overlooked, 
and  they  come  under  treatment  first  when  secondary  lesions  develop. 

In  almost  all  cases  the  chan- 
cre is  solitary;  if  more  than  one 
is  present,  all  have  been  inocu- 
lated at  the  same  time,  usually 
from  numerous  secondary  le- 
sions (Fig.  1009).  The  chancre 
is  not  auto-inoculable;  a  person 
who  has  a  chancre  has  de- 
veloped a  constitutional  disease 
which  runs  a  regular  course, 
and  he  is  immune  to  re-inocu- 
lation (from  his  own  sores  or 
sores  of  others)  until  the  dis- 
ease is  absolutely  eradicated. 
In  all  cases  the  chancre  is 
indurated,  at  some  time  in  its 
development.  Sometimes  in- 
duration appears  before  erosion 
of  the  epithelium  occurs,  and 
usually  it  persists  after  the  ulcer  has  cicatrized.  The  induration 
of  a  chancre  causes  it  to  feel  like  a  piece  of  parchment  or  a  split 
pea  in  the  skin,  and  often  the  chancre  can  be  picked  up,  as  it 


Fig.  1010. — Chancre,  duration  one  day;  ex- 
posure two  weeks  ago.  (Also  left  varicocele.) 
Age  twenty-one  years.  Note  induration.  Ulcer 
can  be  picked  up  in  forceps  without  folding 
on  itself.    Episcopal  Hospital. 


lOlli 


VENEREAL  DISEASES 


were,  without  causing  it  to  fold  on  itself  or  wrinkle  (Fig.  1010).  In 
cases  where  induration  is  less  evident,  it  is  best  detected  by  slight 
rigidity  of  the  prepuce  as  this  rolls  back  from  the  corona  glandis 
(Fig.  1<)1.'5).    This  is  not  an  inflammatory  induration:  the  outlines  of  a 

chancre  (almost  invariably  round 
or  oval)  are  sharply  defined;  and 
there  is  no  redness,  heat,  swelling, 
or  abundant  secretion  from  the 
eroded  or  ulcerated  surface.  The 
surface  of  a  chancre  on  a  mucous 
membrane  may  be  moist,  and 
covered  with  a  thin  pellicle  of 
fibrin;  but  one  on  an  exposed 
surface  usually  is  covered  with  a 
dry  brownish  scab. 

The  duration  of  a  chancre  is 
self-limited.  It  heals  spontane- 
ously in  a  few  weeks  or  months 
unless  complications  arise.  It 
leaves  a  very  characteristic  cica- 
trix, which  usually  but  not  always, 
may  be  identified  years  later  by 
its  circular,  shiny,  slightly  de- 
pressed appearance  (Figs.  1011 
and  1012). 
A  mixed  chancre  is  a  sore  in  which  both  the  syphilitic  and  chancroidal 
viruses  have  been  inoculated.1    Usually  both  poisons  have  been  inocu- 


1 

. 

A 

A 

Fig.  1011. — Scar  from  chancre  on  glans 
penis,  seven  months  previously.  Age 
twenty-two  years.  (Note  also  small 
punched-out  ulcer  back  of  prepuce  from  a 
healed  chancroid.)     Episcopal  Hospital. 


Fig.  1012. — Scar  on  body  of  penis  from  chancre  two  years  previously, 
twenty-six  years.     Episcopal  Hospital. 


Age 


1  Until  Bassereau  in  1852  pointed  out  the  clinical  differences  between  chancre 
and  chancroid,  they  were  not  distinguished,  both  being  regarded  as  the  initial 
lesion  of  syphilis.  Rollet  in  1866  was  the  first  to  explain  the  essential  nature  of 
"mixed  chancre." 


SYPHILIS 


104? 


lated  at  the  same  time,  but  this  is  not  always  the  case.     A  chancre 
may  be  inoculated  subsequently  with  chancroidal  virus,  or  vice  versa. 


Fig.  1013. — "Mixed  chancre."  Multiple  chancroids,  appeared  four  weeks  ago,  four 
days  after  coitus.  Induration  present  for  last  week  only.  Note  stiffness  of  prepuce 
as  it  is  rolled  back  from  corona  glandis.    Episcopal  Hospital. 

In  most  cases  the  early  symptoms  and  history  indicate  that  the  lesion 
is  a  chancroid;  and  it  may  be  only  when  the  ulcer  fails  to  heal  and  in- 
duration commences  (Figs.  1013  and  1014),  or  even  not  until  symptoms 

of  secondary  syphilis  appear,  that 
the  true  condition  is  recognized. 

Syphilitic  Bubo. — Very  soon  after 
the  appearance  of  the  chancre, 
the  related  lymph  nodes  (usually 
the  inguinal)  become  enlarged  and 
indurated.  Many  nodes  are  af- 
fected (poly 'ganglionic) ,  and  if  the 


Fig.  1014. — Mixed  chancre.  Lesion 
appeared  five  weeks  ago,  four  days  after 
coitus.     Episcopal  Hospital. 


Fig.  liii.j.-  -Syphilitic  buboes.  Age  seven- 
teen years.  Coitus  January  15,  chancre  of 
glans  penis  developed  February  7.  Photo- 
graphed March  22,  1909.  Episcopal  Hos- 
pital. 


104S 


VENEREAL  DISEASES 


inguinal  region  is  involved,  almost  invariably  the  affection  is  bilateral. 
Usually  the  enlargement  is  moderate  (Fig.  1015),  but  occasionally  I 
have  seen  great  lumps  the  size  of  oranges  develop.  The  individual 
nodes  do  not  tend  to  coalesce,  they  remain  discrete;  their  outlines 
are  recognizable  on  palpation;  they  are  neither  especially  painful  nor 
very  tender;  they  show  no  evidences  of  acute  in/lamination,  and  never 
suppurate.  These  features  serve  to  distinguish  syphilitic  from  chan- 
croidal  bubo,  which  is  unilateral,  inflammatory,  very  painful;  and  in 
which  suppuration  is  frequent. 


Fig.  1016.- 


-Macular  syphiloderm;  duration  seven  days;  chancre  three  months 
ago.     Episcopal  Hospital. 


Symptoms  and  Diagnosis  of  Secondary  Lesions. — As  noted  in 
Chapter  III,  various  prodromal  symptoms  (fever,  malaise,  headache, 
vague  "rheumatic"  pains)  often  occur  during  the  period  between  the 
development  of  the  chancre  and  the  appearance  of  secondary  lesions. 
This  period  lasts,  on  the  average,  about  six  weeks.  At  the  end  of  this 
time,  often  before  the  chancre  has  healed,  sometimes  after  its  existence 
has  been  almost  forgotten,  and  occasionally  as  the  first  recognized 


SYPHILIS 


1049 


symptom  of  syphilis  (the  chancre  having  passed  unnoted) ,  there  appear 
skin  rashes  which,  though  multiform  and  various,  possess  certain 
characteristics  by  means  of  which  their  syphilitic  nature  usually 
may  be  recognized.  About  this  same  time  the  lymph  nodes  all  over 
the  body  become  enlarged,  especially  the  posterior  cervical  and  epi- 
trochlear  groups.  This  lymphatic  involvement  is  very  characteristic, 
and  often  can  be  relied  on  for  diagnosis  when  the  skin  rashes  are 
too  faint  or  fleeting  for  recognition.      There  is  also  falling  of  the 

hair  (alopecia  syphilitica) ; 
and  sore  throat,  from  de- 
velopment in  the  pharynx 
of  lesions  which  correspond 
to  the  skin  rashes.  Affec- 
tions of  the  eye,  especially 
iritis,  sometimes  occur. 


Fig.  1017.  —  Papular  syphiloderm,  scaling 
(syphilitic  psoriasis);  duration  one  month; 
chancre  three  months  ago.  Episcopal  Hos- 
pital. 


Fig.  1018.  — ■  Papulosquamous 
syphiloderm ;  chancre  seven  months 
ago.     Episcopal  Hospital. 


The  occurrence  in  combination  of  skin  rashes,  lymphatic  enlarge- 
ment, falling  of  the  hair,  and  sore  throat  is  almost  pathognomonic  of 
secondary  syphilis. 

Syphilodermas.—  The  skin  rashes  of  secondary  syphilis  require  more 
extended  description.  They  are  characterized  (1)  by  the  so-called 
protean  nature  of  the  eruption,  or  the  appearance  simultaneously,  or 


L050 


VENEREAL  DISEASES 


in  quick  succession,  or  more  than  one  variety;  (2)  by  their  appearance 
symmetrically,  all  over  the  body;  (3)  by  the  absence  of  subjective  symp- 
toms, the  lesions  causing  no  sensation  of  itching,  burning,  etc.;  and 
(4)  by  the  ham-red  or  coppery  color  of  the  lesions,  especially  as  they 
fade  away.  They  are  distinguished  from  the  skin  lesions  of  tertiary 
syphilis:  (1)  by  their  appearance  within  a  more  or  less  definite  interval 
after  the  primary  lesion;  this  is  not  true  of  tertiary  lesions;  (2)  by 
their  general  and  symmetrical  distribution;  tertiary  skin  lesions  are 
local  and  asymmetrical;  (3)  they  do  not  spread  centrifugally  and 
hence  do  not  assume  the  circinate  and  serpiginous  character  of 
tertiary  lesions;  (4)  they  tend  to  disappear  spontaneously  after 
lasting  a  few  weeks  or  months,  even  without  treatment;  and  their 
disappearance  is  markedly  hastened  by  mercurial  treatment. 

Macular  rashes  (erythema  and  roseola)  usually  are  the  first  to  appear 
(Fig.  1016);  they  may  become  apparent  only  after  the  patient's  body 
has  been  exposed  to  the  air.    Examination  in  a  good  light  is  necessary. 


Fig.  1019. 


-Mucous  patches  around  the  labia  and  anus  of  a  colored  woman. 
Pennsylvania  Hospital. 


Papular  rashes  also  occur  early.  Papules  which  are  exposed  tend 
to  scale,  and  the  lesion  may  resemble  psoriasis  (Fig.  1017).  A  papular 
eruption  which  occurs  late  is  more  deeply  situated  in  the  skin,  and 
bears  a  slight  resemblance  to  tertiary  lesions  (Fig.  1018).  Papules 
which  occur  in  a  group  on  the  forehead,  just  below  the  hair  line,  tend 
to  become  confluent  and  are  termed  the  corona  Veneris.  Papules 
which  occur  on  mucous  membranes,  or  on  skin  surfaces  which  are 
moist  and  wrarm  (anus,  scrotum,  labia,  infra-mammary  folds)  have 
their  epithelial  covering  destroyed  by  maceration;  they  are  known  as 
mucous  patches,  or  if  confluent,  as  condylomata  lata  (Fig.  1019). l    They 

1  The  condyloma  latum,  or  flat  wart,  is  so-called  to  distinguish  it  from  the  ordinary 
venereal  wart  or  condyloma  acuminatum  (p.  1105). 


SYPHILIS  1051 

should  be  looked  for  in  the  situations  named,  as  well  as  in  the  buccal 
mucous  membrane  (cheeks,  palate,  fauces,  tonsils,  tongue). 

Pustular  rashes  occur  later  than  the  macular  and  papular,  usually 
several  months  after  the  primary  lesion.  The  chief  varieties  are 
ecthyma,  acne,  and  impetigo.  If  deep  ulcers  are  formed,  character- 
istic round,  white,  shiny  cicatrices  are  left. 

Symptoms  and  Diagnosis  of  Tertiary  Syphilis. — Usually  there  is 
an  interval  of  a  few  or  many  years  between  the  disappearance  of 
secondary  symptoms  and  the  occurrence  of  those  of  the  tertiary 
stage.  Occasionally,  however,  no  interval  elapses,  tertiary  symptoms 
appearing  while  the  skin  rashes  of  the  second  stage  still  are  present. 
In  many  cases  no  tertiary  symptoms  ever  appear,  especially  if  active 
treatment  has  been  persisted  in  throughout  the  secondary  period. 

Tertiary  lesions  may  affect  almost  any  tissue  in  the  body.  Those 
which  occur  in  the  skin,  mucous  membranes,  subcutaneous  tissues, 
eye,  nervous  and  vascular  systems,  muscles  and  fascia,  bones  and 
periosteum,  and  certain  of  the  solid  viscera,  are  of  most  importance 
in  surgery. 

The  skin  lesions  of  tertiary  syphilis  are  deep  and  destructive.  They 
appear  at  no  definite  interval  after  the  primary  lesion,  they  are  localized 
and  not  symmetrical  in  distribution,  they  tend  to  spread  centrifu- 
gally  and  to  assume  a  serpiginous  form,  they  show  no  inclination 
toward  spontaneous  cure,  and  treatment  by  mercury  alone  rarely  is 
very  effective.  Their  chief  forms  are  the  tubercular  (not  tuberculous ; 
see  p.  75),  squamous,  and  rupial. 

Syphilitic  tubercules  are  at  first  reddish  or  coppery  papules,  which 
tend  to  early  ulceration;  as  those  in  the  center  heal,  the  tubercules 
at  the  periphery  become  ulcerated,  producing  a  serpiginous  lesion 
(Fig.  1020)  which  usually  is  easily  recognized.  Syphilitic  tubercules 
occur  frequently  about  the  eye  and  nose;  where  it  is  important  to 
distinguish  them  from  lupus,  and  rodent  ulcer.  The  scar  which 
results  from  a  tubercular  ulceration  is  large  and  quite  characteristic 
(Fig.  1021);  it  will  be  noted,  in  the  patient  represented  in  this  photo- 
graph, that  although  both  knees  (symmetrical  portions  of  the  body) 
have  been  affected,  the  lesion  on  the  left  side  developed  seventeen 
years  after  that  on  the  right. 

Squamous  lesions  often  attack  the  palms  and  soles,  where  cracks 
and  fissures  are  frequent,  and  may  be  very  painful. 

Rupia  may  occur  in  one  or  many  patches,  following  a  bullous 
eruption  (Fig.  1022). 

In  the  mucous  membranes  syphilitic  ulceration  may  cause  great 
destruction.  Gummatous  lesions  of  the  tongue  have  been  described  in 
Chapter  XIX.  The  palate,  fauces,  pharynx,  etc.,  may  suffer  severely; 
perforation  of  the  palate  is  not  unusual;  "falling  in"  of  the  nose  is 
frequent;  and  sometimes  the  soft  palate  grows  fast  to  the  vault  of 
the  pharynx,  completely  shutting  off  the  nasal  passages  from  the 
oropharynx.  Strictures  of  the  esophagus,  larynx,  trachea,  and 
occasionallv  of  the  intestinal  canal  occur. 


1052 


VENEREAL  DISEASES 


In  the  subcutaneous  tissues  the  most  frequent  lesion  is  the  syphilitic 
gumma  (Fig.  L023).  Its  clinical  characters  have  been  described  in 
Chapter  III. 

In  the  eye  the  most  frequent  lesion  is  syphilitic  iritis. 

In  the  nervous  system  the  lesions  affect  chiefly  the  brain  and  spinal 
cord,  or  their  membranes.  Lesions  of  the  peripheral  nerves  are  rare. 
Any  lesion  of  the  central  nervous 
system  which  occurs  in  a  patient 
who  has  had  syphilis,  even  many 
years  previously  (Fig.  1024),  should 
be  regarded  as  syphilitic  until  the 
contrary  can  be  proved. 

In  the  arterial  system  the  in- 
fluence of  syphilis  in  causing  aneu- 
rysm has  been  pointed  out  in 
Chapter  X. 


Fig.  1020. — Tuberculo-crustaceous  lesion,  in 
tertiary  stage  of  syphilis.  Duration  nine 
months.     Episcopal  Hospital. 


Fig.  1021.  —  Left  knee,  active 
tubercular  ulceration  of  tertiary 
syphilis  in  a  woman  aged  fifty 
years,  twenty  years  after  the  pri- 
mary lesion.  Right  knee  and  thigh 
show  cicatrices  of  similar  tubercu- 
lar lesions  which  developed  seven- 
teen years  previously  and  were 
three  years  in  healing.  Episcopal 
Hospital. 


Fig.  1022. — Syphilitic  rupia.     Age  twenty-six  years;  duration  five  weeks. 
Chancre  one  year  ago.     Episcopal  Hospital. 

In  the  muscles,  bursse,  tendons,  and  fascia  gummatous  tumors  are 
not  unusual,  limiting  function  by  their  bulk,  by  ulceration,  or  by 
the  cicatrices  which  are  the  result  of  healing.  Syphilitic  panaris  and 
dactylitis  (Fig.  1025)  have  been  described  in  Chapter  XIV. 


SYPHILIS 


1053 


Syphilis  of  the  bones  has  been  considered  in  Chapter  XIV,  and 
that  of  the  joints  in  Chapter  XV. 

Of  the  solid  viscera,  the  lesions  of  tertiary  syphilis  affect  particu- 
larly the  liver,  where  gummas  may  simulate  nodular  carcinoma.  The 
diagnosis  depends  on  the  history  of  the  case,  the  recognition  of  other 
signs  (past  or  present)  of  syphilis,  the  Wassermann  test,  and  the  result 
of  medication.  At  operation  gummas  usually  may  be  recognized  by 
central  softening,  if  recent,  or  by  the  stellate  fibrous  cicatrix  which 
results  when  healing  has  been  uninterrupted.  Excision  may  be 
desirable  if  calcification  occurs.  Syphilis  of  the  spleen  is  rare  and  of 
little  surgical  interest.  Syphilis  of  the  testicle  is  considered  in  Chapter 
XXVIII. 


Fig.  1023. — Gumma  of  neck  and  of  lower 
eyelid,  duration  six  weeks.  Patient  aged 
forty-five  years,  had  gonorrhoea  twenty- 
five  years  previously,  no  history  of  chan- 
cre. Rapid  improvement  under  mixed 
treatment.     Episcopal  Hospital. 


Fig.  1024. — Paralysis  of  left  facial 
nerve  from  intracranial  lesion,  thirty 
years  after  chancre.  Paralysis  of 
sudden  onset  ten  days  ago.  Epis- 
copal Hospital. 


Hereditary  Syphilis. — It  has  already  been  stated  that  this  differs 
from  the  acquired  form  of  the  disease  chiefly  in  having  no  primary 
lesion.  It  may  be  inherited  (1)  from  both  parents;  (2)  from  the  mother, 
infected  either  before  conception  or  during  pregnancy;  or  (3)  from  the 
father  at  the  time  of  conception.  As  the  mother  in  the  latter  circum- 
stances is  able  to  suckle  her  syphilitic  child  without  acquiring  syphilis 
herself  (Colles's  law,  1837),  it  was  formerly  taught  that  she  had  ac- 
quired immunity  from  the  fetus;  but  as  such  a  mother  reacts  positively 


1054 


VENEREAL  DISEASES 


to  the  Wassermann  test,  it  is  now  taught  that  she  has  acquired 
syphilis  from  her  fetus,  and  that  her  refractoriness  to  inoculation  is 
due  to  the  fact  that  she  already  has  the  disease,  though  in  latent  form. 

Prof  eta's  law  (1805),  to  the  effect 
that  a  healthy  child  of  syphilitic 
parents  is  unable  to  contract  syphilis, 
is  now  also  explained  by  the  child 
having  the  disease  in  latent  form, 
since  such  children  give  a  positive 
Wassermann  reaction.  Both  Colles's 
and  Profeta's  laws  are  merely  an 
expression  of  the  fact  stated  at  p. 
1045,  that  any  patient  who  has  devel- 
oped syphilis  is  immune  to  re-inocu- 
lation until  the  disease  is  absolutely 
eradicated. 

Pregnancy,  in  the  case  of  syphilis, 
usually  terminates  in  abortion,  in  mis- 
carriage or  in  still-birth  at  term.  The 
more   attenuated   the   infection,    the 
more  probable  is  the  birth  of  a  living 
child  at  term.    The  child  often  shows 
no  evidences  of  syphilis  at  birth;  but  if  the  disease  is  truly  hereditary 
and  not  acquired  after  birth,  lesions  corresponding  to  those  of  the 
secondary  stage  almost  invariably  appear  before  the  age  of  two  wTeeks. 


Fig.  1025. — Syphilitic  dactylitis,  in 
a  patient  aged  forty-one  years,  twelve 
years  after  chancre.  Episcopal  Hos- 
pital. 


Fig.  102G. — Hereditary  syphilis;  aged  twelve  years.     Hutchinson  teeth;  interstitial 
keratitis;  sabre-blade  tibiae.     Orthopaedic  Hospital. 


SYPHILIS 


1055 


The   earliest   symptoms   are   bullous   skin   eruptions    (pemphigus), 
mucous  patches,  and  coryza  ("the  snuffles").    The  baby  suffers  from 


Fig.  1027. — Saddle-nose  in  hereditary 
syphilis.  Age  twenty-four  years.  Also 
has  genital  infantilism  and  chronic  otitis 
media.     Episcopal  Hospital. 


Fig.  102S. — Hereditary  syphilis.  Age 
fourteen  years;  superficial  gummata 
wrongly  diagnosed  as  tuberculosis  and 
eight  operations  done  during  last  five 
years.  (Dr.  W.  Walker's  case.)  Epis- 
copal Hospital. 


malnutrition  and  looks  wrinkled  and  prematurely  aged.  If  the  period 
of  infancy  is  survived,  further  lesions  seldom  appear  until  the  age 
of  six  years  or  older.  The  most 
characteristic  of  these  lesions  are 
interstitial  keratitis,  "Hutchinson's 
teeth"  (Fig.  1026)  (a  peculiar  notched 
and  inverted  wedged-shaped  con- 
dition of  the  permanent  upper  cen- 
tral incisors,  first  recognized  as 
syphilitic  by  Jonathan  Hutchin- 
son, 1861),  rhagades  or  linear  cica- 
trices at  the  corners  of  the  mouth, 
saddle-nose  (Fig.1027),  dactylitis,  and 
sabre-blade  tibia  (Fig.  519).  Super- 
ficial gummata  may  be  mistaken 
for  tuberculosis  of  the  cervical 
lymph  nodes  (Figs.  102S  and  1029). 
Syphilis  of  the  joints  (p.  545)  is 
common  in  the  hereditary  form  of 
the  disease.  In  many  cases  genital 
infantilism  may  exist  even  if  the         fig,  1029.— Hereditary  syphilis,  sane 

bodv  is  large  and  reasonably  well      Patient  ^^ie-  1',2S'  V'1,-'1'  m°nth?  aftf 
.  j  a   course   of    anti-syphilitic    treatment. 

IOrmed.  Episcopal  Hospital. 


1056  VENEREAL   DISEASES 

Diagnosis  of  Syphilis. — This  has  been  based  for  many  years  solely 
on  the  clinical  findings,  and  as  laboratory  aids  (particularly  the  com- 
plicated Wassermann  test,  1906)  may  not  be  available  immediately, 
it  is  very  important  for  the  surgeon  to  be  able  to  recognize  and  attach 
due  significance  to  the  multiform  symptoms  of  the  disease,  especially 
as  these  often  arc  developed  without  apparent  regularity  and  are 
constantly  modified  by  previous  treatment  or  extraneous  circum- 
stances. Often  very  little  assistance  can  be  obtained  from  the  patients 
themselves,  who  may  be  wilfully  deceptive  in  their  answers  or  who 
may  really  have  failed  to  notice  symptoms  sometimes  trivial  in  them- 
selves and  frequently  spread  over  a  long  term  of  years. 

The  distinction  between  chancre  and  chancroid  is  of  great  importance, 
and  usually  is  possible  clinically  by  attention  to  the  points  enumerated 
at  p.  1062;  but  the  existence  of  mixed  chancres  must  be  remembered, 
and  also  that  both  chancre  and  chancroid  may  be  inoculated  simul- 
taneously but  in  different  parts  of  the  body.  Moreover,  a  person 
already  having  syphilis  may  subsequently  acquire  a  chancroid,  and 
this  may  be  modified  by  the  syphilitic  soil  in  which  it  is  planted. 
Valuable  information  may  be  derived  from  "confrontation,"  or  the 
examination  of  the  individual  from  whom  the  disease  was  contracted; 
but  this  is  seldom  possible  in  this  country.  The  development  in 
later  life  of  lesions  of  tertiary  syphilis  and  a  positive  Wassermann 
reaction  in  patients  having  had  no  known  genital  lesion,  or  only 
chancroids  or  gonorrhea,  show  how  very  difficult  it  may  be  to  exclude 
a  diagnosis  of  syphilis  at  the  time  of  the  original  infection. 

Extragenital  Chancre,  particularly  on  the  lips  and  tongue,  must  be 
distinguished  from  carcinoma.  This  usually  may  be  done  clinically 
by  observing  the  early  palpable  enlargement  of  the  neighboring 
lymph  nodes  in  chancre,  and  the  effect  of  antisyphilitic  treatment. 
Microscopical  study  of  a  section  of  the  suspected  ulcer  is  a  sure 
method,  but  like  other  laboratory  aids  is  not  always  available. 

In  the  diagnosis  of  secondary  and  tertiary  lesions  the  surgeon  must 
rely  not  upon  any  one  or  two  symptoms,  but  upon  the  coexistence  of 
a  number,  and  especially  upon  their  course  and  order  of  development. 
A  surgeon  meeting  with  a  case  of  iritis  or  of  cutaneous  eruption,  or 
of  periosteal  "rheumatism,"  in  a  person  of  notoriously  lax  morality, 
should  not  at  once  jump  to  the  conclusion  that  the  disease  is  syphilitic; 
for  to  do  so  would  be  as  unphilosophical  as  it  might  be  unjust.  If, 
on  the  other  hand,  a  patient  should  suffer  from  frequent  attacks  of 
recurrent  iritis,  copper-colored  eruptions  of  various  forms,  post-cervi- 
cal engorgement,  alopecia,  and  occasional  development  of  mucous 
patches;  or  from  osteoscopic  pains,  indolent  nodes  and  gummatous 
tumors  of  the  areolar  tissue — even  though  such  a  patient  should  appear 
as  virtuous  as  Joseph  or  as  wise  as  Penelope — the  surgeon  might 
reasonably  conclude  that  he  had  to  deal  with  a  case  of  syphilis,  and 
should  direct  his  remedies  accordingly  (J.  Ashhurst,  Jr.). 

Laboratory  Aids  to  Diagnosis. — In  many  of  the  ulcerated  lesions  of 
syphilis,  especially  the  chancre  and  mucous  patches,  it  is  possible  to 


SYPHILIS  1057 

find  the  Treponema  pallidum  by  microscopical  study  of  smears  with 
dark  field  illumination,  or  after  proper  staining.  The  Wassermann 
or  complement-fixation  test  for  syphilis  is  considered  perfectly  reliable 
within  certain  limits.  The  test  is  of  highly  technical  nature,  and 
requires  long  practice  and  vast  experience  for  its  proper  performance; 
many  of  the  tests  are  useless  because  these  exacting  conditions  are 
not  fulfilled.  Then  the  test  sometimes  is  not  positive  during  the 
earliest  stage  of  syphilis  (chancre),  nor  as  a  rule  during  the  second- 
ary stage  if  the  patient  has  been  under  active  antisyphilitic  treat- 
ment. It  is  of  greatest  value  in  the  third  stage  of  the  disease,  and 
in  parasyphilitic  affections,  since  here  the  patient  usually  has  not 
been  under  active  treatment  for  a  long  time,  and  if  the  test  is  posi- 
tive it  may  be  considered  conclusive  evidence  that  the  patient  is 
still  suffering  from  syphilis.  Even  this  does  not  prove,  however, 
that  the  lesion  in  question  is  necessarily  syphilitic.  In  the  case  of 
hereditary  syphilis,  also,  a  positive  Wassermann  reaction  may  indi- 
cate that  a  child  of  syphilitic  parents  is  itself  actively  infected,  or  it 
may  indicate  merely  that  the  child  has  syphilis  in  a  latent  form,  in 
accordance  with  Profeta's  law.  Whether  or  not  a  positive  Wasser- 
mann test  may  be  obtained  in  the  third  or  fourth  generation  of  patients 
suffering  frorrf  latent  syphilis  is  not  certain;  even  in  the  second  genera- 
tion it  is  nearly  impossible  to  prove  that  the  disease  was  not  acquired 
in  very  early  infancy.  Certainly  the  fact  that  the  test  is  positive 
often  is  the  only  evidence,  however  remote,  which  can  be  obtained 
to  indicate  that  the  patient  or  his  ancestors  ever  were  infected  with 
syphilis.  Clinical  observation  convinces  me  that  a  negative  test  is  of 
very  little  value  in  excluding  the  presence  of  latent  syphilis.  The 
therapeutic  test  is  more  reliable. 

Treatment  of  Syphilis.1 — As  syphilis  is  a  general  infection,  consti- 
tutional treatment  is  much  more  important  than  local.  It  has  been 
found  by  several  centuries  of  experience  that  the  most  useful  internal 
remedies  are  mercury  and  the  iodides.  The  first  of  these  is  antiseptic, 
and  probably  acts  directly  on  the  parasite  which  causes  the  disease, 
thus  being  specially  indicated  during  the  active  stages  of  syphilis; 
while  the  iodides,  which  aid  elimination,  are  chiefly  beneficial  (either 
alone  or  combined  with  mercury)  in  the  tertiary  stage.  Since  the  dis- 
covery of  the  microbic  cause  of  syphilis,  renewed  efforts  have  been 
made  to  secure  some  drug  which  shall  once  and  for  all  destroy  the  para- 
sites which  cause  the  disease  and  thus  produce  rapid  cure.  At  first 
it  was  thought  that  this  Sterilisatio  Magna  had  been  provided  in  the 
arsenical  compound  known  as  Salvarsan,  the  six  hundred  and  sixth 
("606")  chemical  synthetically  prepared  by  Ehrlich,  with  this  end 
in  view,  and  furnished  to  the  public  in  1909.  To  this  remedy  have 
succeeded  others  more  or  less  similar.  But  it  has  become  evident  that 
while  these  preparations  are  of  exceedingly  great  efficacy  in  certain 
cases,  their  use  only  supplements  and  does  not  supplant  that  of  mercury 
and  the  iodides. 

1  The  question  of  venereal  prophylaxis  is  mentioned  at  p.  1066. 
67 


105S  VENEREAL  DISEASES 

Throughout  the  continuance  of  the  disease,  strict  rules  of  hygiene 
must  be  observed.  In  alcoholics,  nephritics,  and  the  tuberculous, 
the  prognosis  is  bad.  In  otherwise  healthy  patients  the  disease  is  not 
only  curable,  but  often  rapidly  so.  The  patient  must  not  drink  any 
alcoholic  liquors.  He  must  not  smoke  nor  chew  tobacco,  as  these 
habits  favor  the  development  of  mucous  patches.  He  should  have  his 
teeth  put  into  good  order,  and  should  keep  them  in  good  condition 
throughout  the  disease.  He  must  take  great  care  of  his  skin,  bathing 
frequently  and  paying  special  attention  to  regions  where  mucous 
patches  are  apt  to  develop.  He  must  be  careful  in  his  diet.  He  must 
not  kiss  any  one  on  the  lips;  must  sleep  alone;  must  never  use  a  common 
towel,  drinking  cup,  or  other  utensil  likely  to  spread  contagion. 

Treatment  of  the  First  Stage. — Unless  the  diagnosis  of  chancre  is 
positive,  I  believe  it  is  improper  to  administer  constitutional  treat- 
ment until  the  appearance  of  secondary  symptoms  renders  the  exist- 
ence of  syphilis  certain.  The  reason  for  this  is  that,  if  the  sore  is  not  a 
chancre,  no  secondary  symptoms  will  appear  under  any  circumstances, 
and  if  the  sore  is  wrongly  suspected  of  being  a  chancre,  and  consti- 
tutional treatment  is  administered,  the  subsequent  failure  of  secondary 
symptoms  to  appear  may  be  attributed  to  the  treatment  employed, 
and  both  physician  and  patient  will  still  entertain  the  erroneous  opinion 
that  syphilis  is  present.  Hence  is  apparent  the  extreme  importance 
of  reaching  an  accurate  diagnosis  in  the  first  stage  of  the  disease, 
by  careful  clinical  study  and  laboratory  work. 

If  in  any  manner  the  diagnosis  of  chancre  is  incontestable,  then  the 
patient  should  be  put  upon  constitutional  treatment  at  once,  since 
there  is  very  little  doubt  that  this  will  render  the  subsequent  course 
of  the  disease  less  severe.  The  best  way  to  administer  mercury 
internally  is  in  the  form  of  the  protiodide  (hydrargyri  iodidum 
flavum)  in  doses  of  from  0.008  to  0.016  gram.  The  tolerance  of 
the  patient  for  this  drug  must  be  ascertained,  and  the  dose  must 
be  kept  just  below  this  point.  Usually  it  is  well  to  combine  a  tonic, 
such  as  iron,  with  the  mercury.  Whenever  mercury  is  being  taken, 
the  patient  should  be  directed  to  snap  his  teeth  together  occasionally, 
to  ascertain  the  first  occurrence  of  tenderness  of  the  gums;  the  dose 
is  then  reduced  slightly.  Should  salivation,  unfortunately,  occur,  the 
drug  must  be  stopped  at  once,  and  cleansing  mouth  washes  used. 

Locally,  little  need  be  done  for  the  chancre,  beyond  keeping  it 
clean  and  dusting  it  occasionally  with  some  inert  powder.  Cauteriza- 
tion is  not  only  useless  but  harmful;  and  the  uselessness  of  excision 
with  a  view  of  arresting  the  disease,  was  pointed  out  in  Chapter  III. 
If  the  buboes  which  attend  a  chancre  are  painful,  they  may  be 
covered  with  ichthyol  or  belladonna  and  mercury  ointment,  and 
slight  pressure  may  be  applied  by  a  firm  bandage. 

Treatment  of  the  Second  Stage. — If  constitutional  treatment  has  been 
begun  in  the  first  stage,  no  secondary  manifestations  may  appear; 
but  it  will  still  be  necessary  to  continue  treatment  since  experience 
has  shown  that  not  only  may  its  discontinuance  be  followed  by  the 


SYPHILIS  1059 

appearance  of  secondary  lesions,  but  that  the  occurrence  of  tertiary 
lesions  is  more  certain  and  their  character  more  severe,  while  after 
prolonged  and  proper  treatment  during  the  second  stage  they  usually 
are  mild  if  they  appear  at  all.  A  continuation  of  the  internal  adminis- 
tration of  mercury  is  the  least  distasteful  treatment  for  the  patient, 
and  if  the  protiodide  has  been  given  successfully  during  the  first  stage 
it  may  be  continued  into  the  second ;  or  what  is  probably  better,  the 
bichloride  or  the  biniodide  of  mercury  (hydrargyri  iodidum  rubrum) 
may  be  given  in  doses  of  from  0.004  to  0.008  gram,  three  times  daily 
in  pill  form.  If  a  tonic  seems  indicated,  a  mixture  may  be  made 
up  with  the  compound  tincture  of  gentian,  the  compound  syrup  of 
sarsaparilla,  or  the  tincture  of  the  chloride  of  iron. 

If  the  patient  first  comes  under  treatment  when  the  second  stage  is 
fully  developed,  there  is  no  better  method  to  gain  prompt  control  of  the 
symptoms  than  by  inunctions  of  mercury;  indeed,  I  much  prefer  this 
method  of  administration  in  all  cases,  but  patients  often  object  to  it 
as  uncleanly.  About  4  grams  of  the  Unguentum  Hydrargyri  is  to  be 
rubbed  into  a  non-hairy  part  of  the  body  once  daily.  The  same  part 
of  the  body  should  not  be  employed  again  except  after  an  interval 
of  several  days:  this  is  accomplished  by  using  in  succession  the  two 
sides  of  the  thorax,  the  two  flanks,  and  the  epigastrium.  The  patient 
should  make  the  inunctions  himself;  if  made  by  another,  gloves  should 
be  worn  to  prevent  absorption  through  the  hands.  The  patient 
should  wear  the  same  underclothing  for  a  week  before  bathing  and 
removing  the  excess  of  mercury.  When  the  symptoms  are  thoroughly 
under  control  (usually  within  a  few  weeks)  inunctions  may  be  dis- 
carded if  the  patient  desires,  and  mercury  may  be  administered  by 
mouth,  as  above  described.  Should  active  symptoms  recur,  it  is  best 
to  resume  inunctions  temporarily. 

The  hypodermic  administration  of  mercury  salts  has  been  found  pain- 
ful, dangerous  and  unreliable.  Intramuscular  injections  are  hotly 
advocated  by  E.  L.  Keyes,  Jr.;  he  prefers  a  mixture  of  the  salicylate  of 
mercury  3  parts,  and  alboline  (or  benzinol)  30  parts.  From  0.05  to 
0.10  gram  are  injected  once  or  twice  weekly  into  the  gluteus  maximus. 
Mercurial  fumigations  are  used  by  some,  but  never  have  been  widely 
adopted. 

Administration  of  mercury  in  some  form  should  be  continued  at 
least  for  two  years  and  a  half  after  the  initial  lesion.  Some  follow 
the  intermittent  method:  give  mercury  for  six  months,  then  stop 
for  a  month;  then  give  it  for  three  months,  then  stop  for  two  months. 
This  includes  the  first  year.  During  the  second  year  mercury  is  given 
for  eight  months  at  intervals.  Continuous  administration  is  prefer- 
able; and  after  cessation  at  the  end  of  two  and  a  half  or  three  years, 
the  administration  of  mercury  should  be  resumed  if  symptoms  recur, 
or  if  a  positive  Wassermann  reaction  develops;  and  should  then  be 
continued  at  intervals  until  this  reaction  remains  constantly  negative, 
even  after  treatment  has  been  stopped  for  some  months. 


1060  VENEREAL  DISEASES 

Treatment  of  the  Third  Stage. — Here  the  iodides  should  be  taken, 
usually  in  combination  with  mercury  (especially  the  red  iodide,  0.002 
to  0.004  gram),  which  markedly  enhances  their  effectiveness.  Potas- 
sium or  sodium  iodide  may  be  given  in  doses  beginning  with  0.30 
to  0.65  gram,  thrice  daily,  and  increased  to  a  point  just  short 
of  iodism.  In  deep  lesions,  especially  of  bone,  immense  doses  are 
tolerated.  Local  treatment  of  external  lesions  in  this  stage  is  an 
important  adjuvant  to  constitutional  treatment,  but  without  the 
latter  is  absolutely  inefficient. 

Treatment  of  Hereditary  Syphilis. — If  either  parent  is  syphilitic 
the  mother  should  be  treated  during  pregnancy.  This  reduces  the 
chance  of  miscarriage,  and  favorably  influences  the  course  of  the  dis- 
ease in  the  child.  Treatment  of  the  mother  should  be  continued 
throughout  lactation  for  the  infant's  sake,  quite  apart  from  any 
indication  for  treatment  on  her  own  part.  Inunction  is  the  safest 
and  surest  method  of  administering  mercury  to  the  baby;  half  a  gram 
of  blue  ointment  may  be  spread  on  the  infant's  binder,  daily,  and 
allowed  to  work  its  way  into  the  skin  by  the  baby's  movements.  For 
later  lesions  (bones  and  joints)  iodides  also  should  be  given.  In  most 
cases  tonics  are  indicated,  especially  iron  and  quinine. 

Treatment  of  Syphilis  by  Salvarsan,  Arsphenamin,  etc. — These  are 
powerful  antiseptics,  and  rapidly  kill  any  syphilitic  parasites  with  which 
they  are  brought  into  direct  contact.  They  have  no  eliminative  action 
like  the  iodides,  and  are  useless  for  lesions  to  which  they  cannot  be 
conveyed  directly  through  the  blood  stream.  They  are  adminis- 
tered by  intravenous  injection.  The  usual  dose  of  salvarsan  is  0.6 
gm.,  in  40  c.c.  of  freshly  prepared  and  sterile  physiological  salt  solu- 
tion. This  mixture  is  rendered  alkaline  by  adding,  drop  by  drop, 
1  c.c.  of  a  15  per  cent,  solution  of  sodium  hydrate,  constantly  agitating 
the  mixture.  Then  enough  salt  solution  is  added  to  make  300  c.c. 
Thus  each  50  c.c.  of  the  entire  mixture  contains  0.1  gm.  of  salvarsan. 

Though  occasional  deaths,  and  a  few  cases  of  blindness  and  serious 
lesions  of  the  central  nervous  system  have  been  recorded  as  following 
the  use  of  these  drugs,  and  presumably  caused  by  them,  no  hesitation 
need  be  entertained  in  their  employment  in  any  case  where  a  rapid 
amelioration  of  symptoms  is  imperative.  That  such  treatment  is 
absolutely  curative  in  some  cases  is  indicated  not  alone  by  the  sudden 
and  permanent  disappearance  of  all  symptoms,  but  also  by  the  per- 
sistently negative  Wassermann  tests,  and  in  a  few  instances  by  the 
fact  that  patients  have  lost  their  immunity  to  syphilis  and  have  again 
acquired  the  disease.  In  most  cases  it  is  necessary  to  continue  the 
use  of  mercury  and  the  iodides  after  the  injection  of  arsphenamin, 
even  if  this  has  been  repeated  one  or  more  times,  as  it  may  be  at 
intervals  of  not  less  than  one  week. 

CHANCROID. 

The  Chancroid,  or  Ulcus  Molle  (to  distinguish  it  from  the  syphilitic 
chancre  or  ulcus  durum),  is  now  generally  believed  to  be  caused  by 


CHANCROID  1061 

infection  with  the  Bacillus  of  Ducrey  (1889).  According  to  Sovinsky 
(1904)  a  pure  culture  of  this  bacillus  will  produce  chancroids  in  man 
and  in  animals.  The  infection  is  strictly  local,  and  always  is  acquired 
by  inoculation  from  a  similar  sore.  Usually  it  is  acquired  in  coitus,  but 
mediate  transmission  is  possible.  The  lesion  is  auto-inoculable;  from 
its  first  appearance  and  so  long  as  it  remains  unhealed,  other  chancroids 
may  be  inoculated  from  the  pus  which  flows  over  the  surrounding 
skin. 

Chancroid  occurs  oftenest  on  the  genital  organs — especially  on  the 
prepuce,  corona  glandis,  frenum,  and  urinary  meatus  in  the  male; 
and  in  the  female  on  the  labia  or  os  uteri.  But  any  part  of  the  body 
exposed  to  the  contagion  may  be  inoculated.  It  is  not  very  rare  for 
inoculation  to  occur  through  unbroken  skin;  but  usually  some  minute 
abrasion  or  excoriation  is  already  present. 

Clinical  Course  and  Symptoms.— There  is  no  distinct  period  of 
incubation.  Usually  the  next  day  after  exposure  the  patient  feels  an 
itching  or  tingling  at  the  point  of  inoculation;  a  minute  papule  rapidly 
forms,  and  this  in  another  day  becomes  a  vesicle,  then  a  pustule 
which  either  ruptures  and  exposes  an  ulcer,  or  becomes  scabbed. 
Thus  by  the  fourth  to  sixth  day  the  lesion  is  fully  developed.  An  ulcer 
which  appears  later  than  the  tenth  day  after  exposure  is  not  a  chan- 
croid. In  about  80  per  cent,  of  cases  multiple  chancroids  are  present. 
These  may  have  been  inoculated  simultaneously,  or  may  have  been 
inoculated  one  after  the  other  from  the  single  original  lesion. 

A  chancroid  appears  as  a  rounded  or  oval  ulcer,  apparently  punched 
out  of  the  skin,  with  sharply  defined  and  undermined  margins  (Fig. 
1014).  It  varies  in  size  from  less  than  0.5  cm.  to  1.5  cm.  in  diameter; 
it  is  not  adherent  to  the  underhung  tissues,  is  surrounded  at  first  by 
a  reddened  area  of  inflammatory  reaction,  discharges  profusely  pus 
which  is  auto-inoculable,  and  is  covered  by  an  adherent  grayish  slough. 
There  is  a  certain  amount  of  inflammatory  induration  about  the  base 
of  a  chancroid,  but  it  is  not  sharply  limited  and  does  not  resemble 
the  parchment -like  induration  so  characteristic  of  true  chancre. 

Chancroidal  Bubo. — In  many  cases,  but  not  in  all,  the  related  lymph 
nodes  become  inflamed,  and  suppuration  is  very  frequent.  This 
complication  usually  develops  within  the  first  two  weeks,  but  occasion- 
ally not  for  several  weeks  after  the  chancroid  has  healed.  Suppura- 
tion in  the  bubo  may  result  from  secondary  infection  of  the  chancroid 
with  pyogenic  microbes  (the  bubo  being  then  similar  to  the  ordinary 
bubon  (Temblee,  p.  299),  or  may  de  due  to  direct  absorption  through 
the  lymphatics  of  the  Bacillus  of  Ducrey.  Absorption  of  toxins 
produced  by  this  bacillus  is  not  a  sufficient  explanation.  It  is  believed, 
however,  that  the  Bacillus  of  Ducrey  is  self -destroyed  by  the  toxins 
it  produces  in  the  bubo,  and  this  is  held  to  explain  the  difficulty  of 
obtaining  cultures  or  smears  of  the  organism  from  the  abscess. 

A  chancroidal  bubo  almost  always  is  unilateral  (Fig.  1030),  usually 
on  the  same  side  of  the  body  as  the  chancroid  itself.  It  is  distinctly 
inflammatory  in  character  from  the  first,  and  in  no  way  resembles 


1062 


VENEREAL  DISEASES 


the  indolent  syphilitic  bubo  in  which  many  separate  lymph  nodes  are 
palpable. 

Phagedenic  Ulceration  occasionally  occurs  in  chancroid,  especially 
in  patients  who  are  in  poor  constitutional  condition  from  alcoholic 
or  venereal  excesses,  or  who  are  tuberculous.  Serpiginous  ulceration 
also  is  rare;  usually  it  is  seen  in  the  case  of  inguinal  buboes  which  have 
been  opened  without  due  attention  to  cleanliness,  and  have  become 
secondarily  infected  with  the  discharges  from  the  original  chancroid 
(Fig.  1032). 

Other  complications  are  phimosis,  para-phimosis,  balano posthitis, 
coexistence  of  syphilis  or  of  gonorrhea,  etc. 


Fig.  1030. — Left  inguinal  bubo,  one  week  after  development  of  chancroid  on  frenum. 
No  bacillus  of  Ducrey  found  in  pus,  and  bubo  healed  promptly  after  incision.  Episcopal 
Hospital. 


Diagnosis  of  Chancroid. —  Herpetic  eruptions  on  the  genitalia 
develop  almost  immediately  after  coitus,  do  not  form  ulcers  by  the 
third  or  fourth  day,  but  disappear  spontaneously.  They  are  not 
auto-inoculable.  Yet  a  chancroid  may  develop  in  an  herpetic  vesicle, 
and  therefore  a  distinction  before  the  third  or  fourth  day  is  not  always 
possible.  A  chancre  appears  about  three  weeks  after  coitus,  not  within 
a  few  days;  it  is  single,  unless  multiple  from  the  first,  whereas  chan- 
croids usually  are  multiple  even  if  single  at  first.  A  chancre  is  a  super- 
ficial erosion  or  an  ulcer  with  hard,  elevated,  sloping  edges,  not  a 
punched-out  ulcer  with  undermined  edges;  it  presents  a  peculiar 
parchment-like  induration  and  is  not  surrounded  by  a  reddened 
inflammatory  base;  it  is  almost  invariably  accompanied  by  double 
inguinal  bubo,  which  rarely  if  ever  suppurates,  while  chancroid  often 
has  no  bubo  and  if  one  occurs  it  is  unilateral  and  almost  always  sup- 
purates; a  chancre  has  an  innate  tendency  to  heal  but  is  followed  by 
constitutional  symptoms  of  syphilis,  while  a  chancroid  has  no  innate 
tendency  to  heal  and  is  never  followed  by  syphilis  unless  a  mixed 
chancre  (p.  1046)  is  present.  One  attack  of  chancroid  affords  no  pro- 
tection against  subsequent  attacks. 


CHANCROID 


10G3 


Treatment  of  Chancroid. — Some  mild  chancroids  may  heal  under 
ordinary  antiseptic  dressings.  It  is  possible  ,  however,  that  such 
sores  are  not  true  chancroids  but  only  herpetic  ulcerations  infected 
by  pyogenic  cocci.  In  most  chancroids  the  surest  and  occasionally 
the  only  way  to  secure  healing  is  to  destroy  the  specific  microbes  by 
cauterization.  For  this  purpose  I  have  never  found  anything  so 
efficient  as  fuming  nitric  acid.  Some  surgeons  much  prefer  carbolic 
acid,  or  even  the  actual  cautery.  If  the  chancroid  is  large,  or  the 
patient  very  timid,  it  may  be  necessary  to  administer  an  anesthetic. 
But  in  the  average  dispensary  case  (and  it  is  only  in  the  lowest  class 
of  such  patients  that  chancroids  are  seen — it  is  a  disease  of  filth)  no 
anesthetic  is  necessary.  Cauterization  should  not  be  employed  unless 
the  diagnosis  is  certain;  it  produces  induration  and  makes  difficult 
a  distinction  from  the  initial  lesion  of  syphilis.  When  it  is  employed, 
thoroughness  is  requisite.  The  best  way  to  apply  nitric  acid  is  by 
means  of  a  stick  about  the  size  of  a  pencil  smoothly  rounded  off  at  one 
end.  The  surrounding  healthy  skin  should  be  protected  from  the  acid 
by  smearing  it  with  olive  oil  or  vaselin,  and  the  ulcer  is  dried.  The 
stick  is  then  dipped  in  the  acid,  and  is  vigorously  rubbed  into  the 
ulcerated  surface,  overlooking  no  corner  or  cranny.  This  destroys 
the  specific  microbes,  and  when  the  resulting  crusts  separate  it  will 
be  found  that  a  healthy  granulating  surface  is  left  which  will  soon 
heal  under  ordinary  antiseptic  dressings  or  ointments.  If  healing 
does  not  proceed  normally,  cauterization  must  be  repeated,  but  this 
is  very  seldom  necessary  if  it  has  been  properly  done  in  the  first 
place. 


Fig.  1031. — Dorsal  slit  of  prepuce  to  expose  chancroids  of  mucous  surface  of  prepuce. 
Note  inflammatory  thickening  of  prepuce.     Episcopal  Hospital. 

If  the  chancroid  is  inaccessible  on  account  of  phimosis,  the  foreskin 
should  be  slit  up  the  dorsum  (Fig.  1031),  under  procain;  then  the  cut 
edges  and  the  exposed  chancroids  are  to  be  cauterized.  I  have  never 
seen  a  case  where  an  efficient  dorsal  slit  did  not  give  enough  exposure. 

Treatment  of  Chancroidal  Bubo. — It  is  useless  to  attempt  to  treat 
the  bubo  until  the  infecting  focus  (chancroid)  has  been  cured,  since 


1004 


VENEREAL  DISEASES 


fresh  inoculation  will  constantly  occur  through  the  lymphatics. 
Prompt  treatment  of  the  chancroid  itself,  as  indicated  above,  fre- 
quently is  sufficient  to  cause  the  bubo  to  disappear,  even  when 
suppuration  appears  to  threaten. 

I  do  not  think  it  is  advisable  to  open  a  chancroidal  bubo  until 
suppuration  is  very  evident;  the  longer  the  pus  remains  in  the  abscess, 
the  more  apt  it  is  to  sterilize  itself  of  the  chancroidal  virus.  Yet 
spontaneous  rupture  of  the  abscess  is  to  be  avoided  at  all  hazards, 
especially  if  the  chancroid  itself  is  unhealed;  since  then  the  opened 
bubo  will  become  infected  by  the  discharges  from  the  chancroid,  and 


Fig.  1032.— Chancroidal  ulcer.  Age  fifty-five  years.  Duration  ten  weeks.  Bubo 
developed  soon  after  chancroid  of  glans,  and  was  allowed  to  rupture  spontaneously; 
the  ulcer  then  became  infected  with  the  chancroidal  virus,  and  showed  no  tendency  to 
heal.    Treated  by  excision.    Episcopal  Hospital. 

will  be  converted  into  a  chancroidal  ulcer  (Fig.  1032).  When  the  bubo 
is  to  be  opened,  this  should  be  done  with  careful  antiseptic  precautions. 
Where  this  precaution  has  been  taken,  and  where  the  original  chancroid 
was  no  longer  a  source  of  infection,  I  have  never  seen  any  bubo  that 
did  not  heal  promptly  under  ordinary  antiseptic  dressings.  If  the 
bubo  after  it  is  opened  becomes  converted  into  a  chancroidal  ulcer, 
as  indicated  above,  it  must  itself  be  treated  as  the  original  chancroid; 
or  the  ulcer  may  be  excised  and  the  resulting  wound  cauterized. 


GONORRHEA. 


Gonorrhea  is  a  local  infection  of  mucous  membranes  caused  by  gono- 
coccus  (Neisser,  1879;  Bumm,  1887).  This  is  a  diplococcus  which  is  a 
pure  parasite,  growing  best  at  body  temperature  and  soon  perishing 
when  discharged  from  the  body.  It  is  readily  killed  by  heat,  and  does 
not  survive  long  in  dried  secretions.  Mucous  membranes  with  cylin- 
drical-celled epithelium  are  much  more  easily  infected  by  the  gonococ- 
cus  than  are  those  covered  with  pavement  epithelium.  The  gonococcus 


GONORRHEA  1065 

is  found  in  the  purulent  exudate,  within  the  leukocytes,1  and  invades 
the  submucous  tissues  easily;  it  spreads  through  the  lymphatics, 
enters  the  blood  stream,  and  may  produce  a  general  infection  (a  mild 
form  of  pyemia).  In  the  latter  circumstances  secondary  localizations 
in  serous  membranes  are  frequent.  One  such  localization,  gonococcic 
arthritis,  has  been  studied  in  Chapter  XVI ;  gonococcic  endocarditis  is 
treated  by  the  physician;  and  gonococcic  iritis  by  the  ophthalmologist. 
Whether  or  not  gonococcic  conjunctivitis  (gonorrheal  ophthalmia) 
ever  occurs  by  infection  through  the  blood-stream  is  disputed;  cer- 
tainly in  most  cases  infection  occurs  by  mediate  contagion  through 
soiled  towels,  etc. 

Gonococcic  Urethritis. — Urethral  inflammation  due  to  infection 
by  the  gonococcus  is  the  commonest  venereal  disease.  In  the  female 
the  infection  localizes  itself  especially  in  the  vulvovaginal  canal,  not 
so  much  in  the  urethra.  In  man  the  infection,  acquired  in  sexual 
intercourse,  becomes  localized  in  the  anterior  urethra,  especially  the 
fossa  naviculars;  unless  there  is  phimosis,  causing  retention  of  secre- 
tions, the  glans  penis  and  prepuce  usually  escape  infection  owing 
to  the  character  of  their  epithelial  covering.  From  the  anterior 
urethra  the  inflammation  usually  spreads  throughout  the  entire  canal, 
and  is  especially  apt  to  remain  localized,  in  chronic  form,  in  the  deep 
urethra  and  prostate.  Throughout  the  urethra  the  submucous  tissues 
are  invaded,  and  inflammation  of  the  glands  of  Littre  is  common; 
these  may  be  converted  into  abscesses,  which  rupture  into  the  urethra 
or  rarely  externally.  Inflammation  of  Cowper's  glands  is  more  apt 
to  result  in  external  rupture,  and  is  the  chief  cause  of  periurethral 
abscess  (p.  1082)  and  periurethral  urinary  fistula?.  The  healing  of 
these  patches  of  inflammation  or  follicular  abscesses  may  result  in 
the  formation  of  urethral  strictures  (p.  1074). 

Symptoms  and  Clinical  Course. — 1.  In  Acute  Gonococcic  Urethritis, 
vulgarly  known  as  the  clap,  the  first  symptoms  usually  appear  on  the 
third  or  fourth  day  after  contagion,  and  consist  in  tingling  and  itching 
of  the  urinary  meatus.  On  inspection  the  lips  of  the  meatus  are  found 
swollen,  and  there  is  a  slight  glairy  discharge  which  causes  them  to 
adhere  between  the  acts  of  urination.  A  scalding  sensation  in  passing 
water  is  very  frequent.  One  or  two  days  later  a  profuse  purulent, 
sometimes  blood-stained  discharge  appears;  the  ardor  wince  lessens; 
painful  erections  are  frequent;  and  edema  of  the  foreskin  may  occur 
with  phimosis  or  paraphimosis  (Fig.  1065)  and  resulting  balano-posthitis. 
Later,  during  erection,  the  penis  may  be  bent  downward  or  laterally 
(chordee) ;  this  painful  symptom  is  due  to  the  inability  of  the  spongy 
portion  of  the  penis,  which  surrounds  the  inflamed  urethra,  to  become 
elongated  to  the  same  extent  as  the  cavernous  bodies.  Epididymitis 
(p.  1108)  is  another  frequent  complication.  In  almost  all  cases  of 
gonorrhea  the  inflammation  extends  within  a  week  or  ten  days  to  the 

1  Some  pathologists  hold  that  unless  the  diplococci  in  question  are  intracellular 
they  cannot  be  certainly  classed  as  gonococci;  legal  proof  requires  the  growth  of 
a  pure  culture. 


10(30  VENEREAL  DISEASES 

posterior  urethra.  This  event  may  pass  unnoticed,  or  may  be  evi- 
denced by  increasing  frequency  of  micturition,  vesical  tenesmus,  and 
sometimes  by  temporary  lessening  of  the  discharge.  Then  as  these 
symptoms  abate,  the  discharge  may  again  increase.  Even  in  severe 
cases,  constitutional  symptoms  usually  are  absent. 

Acute  gonococcic  urethritis  tends  to  run  a  self-limited  course,  almost 
all  symptoms  disappearing  within  six  to  ten  weeks,  no  matter  what 
treatment  is  employed,  or  even  if  no  treatment  is  employed;  but  proper 
treatment  usually  hastens  subsidence  of  symptoms.  In  almost  all 
cases,  however,  subsidence  of  acute  symptoms  does  not  indicate  that 
the  disease  is  cured,  but  merely  that  it  has  become  chronic  or  latent. 
The  gonococci  remain  localized  in  the  deep  urethral  crypts,  in  the 
prostatic  utricle,  prostate  gland,  or  seminal  vesicles,  and  after  any 
excess  in  eating  or  drinking,  after  excessive  coitus,  and  sometimes  from 
no  ascertainable  cause,  a  urethral  discharge  containing  gonococci  will 
appear,  may  cause  a  temporary  renewal  of  acute  symptoms,  and  is 
capable  of  conveying  contagion  to  another  individual. 

2.  Chronic  Gonococcic  Urethritis,  known  also  as  the  gleet,  is  a  very 
frequent  sequel  of  acute  posterior  urethritis.  The  symptoms  are 
insignificant,  the  most  constant  being  slight  mucous  or  purulent  dis- 
charge (perhaps  only  a  drop  or  two)  from  the  meatus,  observed  when 
the  patient  wakens  in  the  morning.  After  defecation,  or  during  sexual 
excitement,  a  similar  slight  discharge  may  occur.  If  a  sound  is  passed 
into  the  penile  urethra,  the  chronically  inflamed  urethral  glands  often 
may  be  detected  as  small  nodules,  by  running  the  finger  along  the  under 
surface  of  the  penis.  Sometimes  vesical  tenesmus  is  annoying  at 
intervals.  There  may  be  frequent  erections  and  nocturnal  pollutions, 
and  the  seminal  discharge  sometimes  is  blood-stained. 

Diagnosis. — The  diagnosis  of  acute  gonorrhea  usually  may  be  made 
clinically,  but  it  is  always  well  to  stain  a  smear  of  the  discharge  and 
examine  it  for  gonococci.  If  the  anterior  urethra  only  is  involved, 
and  the  patient's  urine  is  collected  in  two  glasses,  the  second  portion 
will  be  clear,  as  the  urine  first  passed  will  have  washed  away  all  the 
secretions.  If,  however,  the  posterior  urethra  is  involved,  the  second 
glassful  of  urine  will  be  cloudy  or  will  contain  shreds  of  mucus,  since 
the  pressure  of  accumulated  secretions  pent  up  in  the  deep  urethra 
can  force  the  vesical  sphincter  and  allow  the  urethral  discharge  to  mix 
with  the  urine  in  the  bladder.  In  chronic  gonorrhea  it  is  indispensable 
to  examine  the  urethral  discharge  for  gonococci.  If  no  secretion  is 
readily  available,  the  prostate  and  seminal  vesicles  should  be  given 
gentle  massage,  as  indicated  at  p.  1069,  to  force  their  contents  into 
the  urethra.  A  number  of  laboratory  examinations  may  be  necessary 
before  gonococci  can  be  found.  In  chronic  urethritis  the  second 
urine  constantly  contains  shreds. 

Treatment.1 — Certain  general  directions  should  be  given  a  patient 
suffering  from  gonorrhea.    He  should  be  warned  of  the  danger  of  con- 

1  The  prevention  of  venereal  disease  is  to  be  regarded  as  a  scientific  and  not 
simply  a  moral  problem.    It  is  self  evident  that  the  simplest  means  of  prevention 


GONORRHEA  1067 

tagion,  especially  of  gonorrheal  ophthalmia;  the  possibility  of  compli- 
cations, especially  epididymitis,  should  be  called  to  his  attention; 
and  he  should  be  instructed  as  to  precautions  concerning  diet,  rest, 
hygiene,  and  cleanliness.  He  should  drink  plenty  of  water,  and  should 
take  no  alcoholic  liquor  at  all,  unless  a  confirmed  drinker.  He  should 
wear  a  suspensory  bandage,  and  if  possible  during  the  acutely  inflam- 
matory stage  he  should  remain  in  bed  with  the  scrotum  elevated. 
The  discharge  should  not  be  kept  dammed  up  in  the  urethra  by 
dressings;  but  the  lips  of  the  meatus  should  be  greased  with  vaselin 
and  the  discharge  collected  in  loosely  applied  absorbent  cotton  which 
is  changed  frequently.  The  presence  of  phimosis  may  add  the  com- 
plication of  balano-posthitis,  and  a  dorsal  slit  of  the  foreskin  may  be 
advisable  to  secure  free  drainage,  especially  if  chancroids  are  thought 
to  coexist.  Meatotomy  should  be  done  if  drainage  through  the  meatus 
is  insufficient.     Paraphimosis  seldom  requires  treatment. 


Fig.  1033. — Urethral  syringe.     (Watson  and  Cunningham.) 

If  the  patient  is  seen  in  the  earliest  stages  of  the  disease,  before 
profuse  discharge  has  commenced,  it  may  be  possible  to  secure  prompt 
arrest  of  the  disease  by  what  is  called  abortive  treatment.  This  consists 
in  the  use  of  antiseptic  injections  into  the  urethra,  the  usual  substances 
employed  being  protargol  (2  to  5  per  cent.)  or  argyrol  (5  to  10  per  cent.) ; 
silver  nitrate,  in  strength  varying  from  1  to  2000  up  to  4  per  cent.,  is 
also  used.  The  patient  should  urinate  before  taking  the  injection,  which 
is  administered  by  means  of  a  glass  urethral  syringe  with  blunt  nozzle 
(Fig.  1033).  Tins  is  carefully  introduced  into  the  meatus,  and  the  lips 
of  the  meatus  are  closed  tightly  around  the  nozzle  by  the  fingers  of  the 
left  hand,  as  the  piston  of  the  syringe  is  pushed  home  with  the  right. 
From  2  to  5  c.c.  of  the  solution  is  injected  twice,  the  second  injection 
being  held  in  the  urethra  for  several  minutes.  These  injections  are 
to  be  used  three  or  four  times  daily,  except  in  the  case  of  the  very 

(abstention  from  impure  coitus)  is  the  most  efficient,  but  cannot  always  be  enforced 
upon  patients.  In  the  case  of  enlisted  men  in  the  army  and  navy  it  has  been  found 
advisable  to  adopt  definite  rules  of  venereal  prophylaxis  since  without  it  the  per- 
centage of  infection  is  verv  high.  Holcomb  and  Gather  (1912)  report  the  results 
in  the  United  States  Navy,  where  the  following  rule  was  enforced  after  every 
known  exposure  to  venereal  disease:  (1)  Wash  the  penis  (head  and  shank  and 
under  frenum)  with  1  to  5000  bichloride  of  mercury  solution,  using  a  cotton  sponge. 
(2)  Pass  the  urine;  and  take  urethral  injection  of  2  per  cent,  protargol  solution 
and  hold  it  in  the  urethra  until  60  has  been  counted.  (3)  Rub  50  per  cent,  calo- 
mel ointment  well  into  foreskin,  head  and  shank  of  penis,  especially  the  frenum. 
They  found  that:  1385  exposures  treated  as  above  in  the  first  eight  hours,  gave 
19  infections,  or  1.37  per  cent.;  731  exposures  treated  as  above  in  eight  to  twelve 
hours,  gave  25  infections,  or  3.4  per  cent.;  920  exposures  treated  as  above  in 
twelve  to  twenty-four  hours,  gave  46  infections,  or  5  per  cent. 


1068  VENEREAL  DISEASES 

strong  silver  nitrate  solutions,  which  should  be  used  only  once  daily 
and  by  the  surgeon  himself,  one  or  two  injections  often  sufficing. 
In  many  cases  in  which  this  abortive  treatment  is  promptly  instituted, 
the  results  are  excellent;  though  the  urethral  discharge  may  be  tem- 
porarily increased,  it  soon  decreases  again,  becoming  glairy  and  per- 
haps blood-stained,  and  then  ceasing  entirely,  within  a  week  or  ten 
days.  In  other  cases  some  discharge  persists,  and  further  treatment, 
as  in  the  chronic  stage,  must  be  instituted. 

If  the  patient  is  seen  first  during  the  inflammatory  stage  of  gonorrhea, 
it  is  not  advisable  to  use  injections,  and  they  should  be  discontinued 
if  previously  employed.  In  this  stage  the  patient  should  remain  in 
bed  if  possible,  with  the  scrotum  well  elevated,  especially  avoiding 
sexual  excitement.  The  penis  should  be  immersed  in  hot  water 
several  times  daily,  as  the  heat  not  only  allays  the  inflammation  but 
is  germicidal  to  the  gonococci.  Internally,  capsules  containing  01. 
copaibse  (0.5  c.c.)  and  Oleores.  cubeb.  (0.2  c.c.)  may  be  given,  with 
or  without  methylene  blue  (0.125  gram)  and  sandalwood  oil  (0.125 
c.c).  Not  until  the  decline  of  the  inflammation  should  injections 
be  resumed,  and  as  the  discharge  loses  its  purulent  character  and 
becomes  mucoid,  the  stronger  antiseptics  may  be  abandoned  and 
astringents  given  by  injection,  such  as  zinc  or  copper  sulphate,  lead 
acetate,  etc.  The  following  is  the  formula  of  the  remedy  known  as 
"brue:"  1$ — Plumbi  acetat.,  2  grams;  Zinci  sulphat.,  1  gram;  Ext. 
krameriae  fl.,  16  c.c;  Tinct.  opii,  12  c.c;  Aquse destillat.  q.  s.  ad  200  c.c 
Internally  such  drugs  as  salol  or  urotropin  are  indicated.  As  the 
discharge  lessens  the  strength  of  the  astringent  injections  should  be 
gradually  diminished. 

The  treatment  of  chronic  gonococcic  urethritis  involves  discovery, 
if  possible,  of  the  habitat  of  the  remaining  germs,  and  their  destruction. 
For  this  purpose  examination  with  the  endoscope  often  is  advisable. 
Through  this  it  may  be  possible  to  detect  superficial  ulcerations  or 
erosions  of  the  urethra,  the  orifices  of  inflamed  urethral  glands,  etc; 
or  by  the  use  of  bulbed  sounds  the  presence  of  a  stricture  of  large 
caliber  (p.  1076)  maybe  determined;  or  with  the  cystoscope  the  pros- 
tatic utricle  and  orifices  of  the  ejaculatory  ducts  may  be  investigated. 
Chronic  prostatitis  and  seminovesiculitis  are  frequent  complications, 
and  it  may  be  impossible  to  discover  gonococci  in  a  chronic  urethral 
discharge  until  after  massage  of  these  structures,  as  described  below. 

For  lesions  of  the  anterior  urethra,  it  is  best  to  give  irrigations  three 
times  weekly.  The  solution  (silver  nitrate,  1  to  10,000;  potassium 
permanganate,  1  to  10,000;  protargol,  1  to  2000)  is  allowed  to  enter  the 
urethra  from  a  fountain  syringe,  by  the  force  of  gravity.  After  the 
urethra  has  been  well  cleansed  in  this  manner,  a  soft  catheter  is  passed 
into  the  bladder,  and  this  is  filled  with  the  solution;  the  catheter  is 
then  withdrawn,  and  the  patient  allowed  to  empty  his  bladder,  thus 
cleansing  the  entire  lower  urinary  tract  (Horwitz).  Strong  applica- 
tions are  then  made  to  the  erosions  through  the  endoscope.  If  there 
is  much  periurethral  infiltration,  the  passage  of  large-sized  sounds 


GONORRHEA  1069 

twice  weekly  is  of  benefit.  Stimulating  ointments  may  be  employed 
by  smearing  them  over  the  sound  and  then  gently  rubbing  the  corpus 
spongiosum  while  the  sound  is  in  place. 

//  lesions  persist  in  the  deep  urethra  it  is  well  to  make  instillations 
of  silver  nitrate  (0.5  per  cent.)  or  protargol  (0.25  to  2  per  cent.)  through 
a  deep  urethral  syringe  (Fig.  1034)  after  massage  of  the  prostate,  which 
is  accomplished  by  introducing  the  index  finger  into  the  rectum,  and 
gently  stroking  the  vesicles  and  each  lobe  of  the  prostate  downward 
toward  the  ejaculatory  ducts.  Too  violent  massage  may  set  up  a 
prostatitis  or  even  a  proctitis.  It  is  usual  to  have  the  patient  stand  in 
a  stooping  posture  for  massage  of  the  prostate,  the  surgeon  standing 
behind  him;  but  if  the  surgeon  has  a  little  practice  and  not  too  short 


Fig.  1034. — Keyes'  deep  urethral  syringe.     (Watson  and  Cunningham.) 

a  finger,  it  is  more  convenient  to  have  the  patient  lying  supine.  Any 
urethral  discharge  which  follows  massage  of  the  prostate  should  be 
examined  for  gonococci,  and  if  these  are  found  persistently  absent 
at  a  number  of  examinations  made  at  intervals  after  stopping  all 
treatment,  the  urethritis  may  be  considered  cured.  Sometimes  pro- 
longed treatment  causes  a  non-gonococcic  urethritis,  and  cessation  of 
local  treatment  and  attention  to  the  patient's  general  health  may  be 
successful  in  stopping  a  discharge  which  seems  otherwise  incurable. 
Microscopical  examination  of  the  discharge  in  such  cases  may  show  the 
presence  of  staphylococci,  streptococci,  or  colon  bacilli.  The  use  of 
autogenous  vaccines  may  be  of  use  in  such  cases,  as  well  as  in  chronic 
gonococcic  urethritis. 


CHAPTER   XXVII. 
SURGERY  OF  THE  URETHRA  AND  PROSTATE. 


SURGERY  OF  THE  URETHRA. 

Bougies  and  Sounds  (Fig.  1035)  may  be  regarded  as  solid  catheters 
(p.  1013).  They  are  used  in  the  diagnosis  and  treatment  of  urethral 
strictures.  The  bougie  (so-called  because  originally  made  of  wax)  is 
flexible;  the  old  French  bougie  a  boule  is  inferior  to  the  modern  bul- 
bous-tipped French  bougies  made  of  webbing,  like  English  catheters. 
The  best  have  a  core  of  lead  which  gives  them  sufficient  weight  to 
facilitate  their  introduction.  Filiform  bougies  are  made  of  whalebone, 
and  should  be  perfectly  flexible  and  highly  polished.  Sounds  are 
metallic  instruments;  they  should  be  highly  polished  or  nickel-plated, 
of  sufficient  weight  to  sink  into  the  urethra  easily,  and  provided  with 


Fig.  1035. — Urethral  sounds  and  bougies:  1.  Steel  sound.  2.  Bulbed  sound.  3. 
Bougie  a  boule.  4.  Olive  tipped  bougie,  made  of  webbing,  with  a  leaden  core.  5,  6,  7, 
Filiform  bougies,  made  of  whalebone. 

a  suitable  handle,  to  prevent  slipping.  They  are  introduced  in  the 
same  way  as  metal  catheters  (Figs.  1036  and  1037).  Bulbed  sounds  cor- 
respond to  the  bougies  a  boule;  they  are  of  use  in  determining  the 
extent  and  site  of  a  stricture,  by  the  sensation  they  impart  to  the 
examiner's  hand  when  the  bulb  catches  on  the  anterior  or  posterior 
face  of  the  stricture. 

Retention  of  Urine. — Retention  of  urine  is  a  condition  which  occurs 
so  often  in  affections  of  the  urethra,  that  it  is  convenient  to  enumerate 
its  varieties  at  the  outset.  First  there  is  (1)  Acute  Complete  Retention: 
the  patient,  previously  able  to  evacuate  his  urine  wholly  or  in  part, 
suddenly  becomes  unable  to  do  so;  all  the  urine  is  retained,  and  the 
( 1070 ) 


FOREIGN  BODIES 


1071 


Fig.  103G. — Passing  a  sound  from  the  pa- 
tient's right  side.  Observe  how  the  sound  is 
held  in  the  fingers,  and  note  that  no  force  can 
be  used.    Episcopal  Hospital. 


condition  is  acute.  (2)  Acute  Incomplete  Retention  occurs  when  the 
patient  is  just  able  to  void  a  few  drops,  with  much  effort;  the  condi- 
tion is  acute,  but  a  little  of  the  urine  is  passed.  (3)  Chronic  Complete 
Retention,  where  the  patient  depends  absolutely  upon  the  catheter 
for  emptying  his  bladder, 
though  the  condition  is 
chronic,  and  the  catheter 
has  been  required  for  months 
or  years.  (4)  Chronic  Incom- 
plete Retention  without  disten- 
tion of  the  bladder,  where  a 
certain  portion  of  urine  is 
constantly  retained,  but  where 
the  major  portion  is  evacuated 
voluntarily;  a  chronic  condi- 
tion, where,  without  the  blad- 
der being  over-filled,  residual 
urine  exists.  Finally  there  is 
(5)  Chronic  Incomplete  Reten- 
tion with  distention  of  the  blad- 
der, where  so  much  of  the 
urine  is  retained  that  the  bladder  has  reached  the  limit  of  its  capacity, 
and  overflow  from  retention  results. 
We  may  tabulate  these  conditions  as  follows: 

I.  Acute  Retention. 

1.  Acute  Complete  Re- 
tention. 

2.  Acute  Incomplete  Re- 
tention. 

Chronic  Retention. 

3.  Chronic  Complete  Re- 
tention. 

4.  Chronic  Incomplete 
Retention  without  dis- 
tention of  the  bladder. 

5.  Chronic  Incomplete 
Retention  with  disten- 
tion of  the  bladder. 

The  first  of  these  conditions 
occurs  oftenest  as  a  complica- 
tion of  stricture  of  the  urethra; 
the  second  in  cases  of  urethritis;  the  third,  fourth,  and  fifth  are  seldom 
seen  except  in  cases  of  enlargement  of  the  prostate. 

Foreign  Bodies. — Foreign  bodies  may  enter  the  urethra  from  the 
bladder  (calculi,  etc.)  or  from  without.  The  end  of  a  catheter  or 
filiform  bougie  occasionally  breaks  off;  and  sometimes  a  patient  passes 
implements  into  the  urethra  to  relieve  some  fancied  obstruction,  and 
the  instrument  breaks  off  or  escapes  from  his  fingers.    There  is  danger 


II. 


Fig.  1037. — The  urethral  sound  fully  intro- 
duced. Note  the  angle  it  makes  with  the 
horizon.     Episcopal  Hospital. 


1072 


SURGERY  OF  THE   URETHRA  AND  PROSTATE 


of  such  bodies  escaping  into  the  bladder,  and  they  may  seriously 
traumatize  the  urethra.  It  is  very  important  not  to  introduce  a 
sound  incautiously  for  the  purposes  of  diagnosis,  since  it  is  apt  to 
push  the  foreign  body  up  into  the  bladder,  or  to  embed  it  in  the  ure- 
thral wall.  It  is  better  to  make  the  diagnosis  by  means  of  the  a>ray, 
whenever  this  is  available.  It  is  rare  for  foreign  bodies  to  produce 
complete  urinary  obstruction,  but  they  scarcely  ever  can  be  washed 
out  by  the  stream  of  urine.  Fortunately  sufficient  time  usually  is 
available  to  send  the  patient  to  a  wrell  equipped  hospital.  There  it 
may  be  possible  to  extract  the  foreign  body  by  the  aid  of  the  endo- 
scope, or  even  by  alligator  forceps  (Fig.  1038)  introduced  closed  and 
opened  when  they  are  felt  to  come  into  contact  with  the  foreign  body. 
Occasionally  a  pencil  or  similar  article  may  be  worked  out  step  by 
step  by  forcing  the  penis  down  over  it  as  it  is  fixed  with  the  fingers 
through  the  perineum  or  the  penile  urethra.  A  hat  pin,  introduced 
into  the  urethra  head  first  may  be  extracted  by  protruding  its  point 

through  the  body  of  the  penis,  re- 
versing it,  and  pushing  it  out  head 
first.  If  all  other  methods  fail  ex- 
ternal urethrotomy  (p.  1078)  should 
be  done;  an  incision  in  the  penile 
urethra  should  be  sutured,  but  one 
in  the  perineum  may  be  left  to 
heal  by  granulation.  If  the  foreign  body  has  escaped  into  the  blad- 
der it  may  be  removed  by  suprapubic  cystotomy,  if  extraction  with 
the  operating  cystoscope  is  impossible. 


Fig.  1038. — Urethral  forceps. 


Fig.  1039. — Extravasation  of  urine  beneath  Colles's  fascia;  duration,  twenty-four 
hours;  from  spontaneous  perforation  of  urethra  behind  a  stricture.  No  injury  had 
occurred  and  no  instruments  had  been  passed.     Episcopal  Hospital. 

Rupture  of  the  Urethra  usually  is  the  result  of  direct  injury 
(falls,  kicks,  etc.)  to  the  perineum;  occasionally  it  occurs  as  a 
complication  of  fracture  of  the  pelvis  or  from  pressure  of  urine 
behind  a  tight  stricture,  in  which  situation  perforation  of  the  urethra 
from  ulceration  may  occur.  The  lesion  almost  always  is  in  the 
subpubic  urethra,  at  the  bulbomembranous  juncture.     The  diagnosis 


RUPTURE  OF  THE  URETHRA  1073 

depends  on  the  history  of  traumatism,  and  the  passage  of  bloody  urine 
or  on  the  symptom  of  "bloody  anuria"  (p.  1026).  In  most  cases 
urinary  extravasation  occurs  after  twenty-four  hours.  If  the  rupture 
occurs  anterior  to  the  superficial  layer  of  the  triangular  ligament,  the 
urine  passes  first  into  the  perineum  and  being  confined  by  Colles's 
fascia  rapidly  forces  its  way  through  the  cellular  tissues  of  the  scrotum 
on  to  the  abdominal  walls,  through  the  abdomino-scrotal  opening 
(Fig.  1039).  If  rupture  occurs  above  the  triangular  ligament,  the 
symptoms  resemble  those  of  extraperitoneal  rupture  of  the  bladder,  but 
the  history  of  injury  to  the  perineum,  with  resulting  ecchymosis, 
etc.,  points  to  the  urethra  as  the  seat  of  the  lesion.  If  urinary  extra- 
vasation is  unrelieved,  extensive  sloughing  will  occur,  especially  if 
the  urine  was  previously  unhealthy ;  constitutional  symptoms  of  sepsis 
are  frequent,  and  death  may  ensue  from  this  cause. 

Treatment. — Treatment  consists  first  in  guarded  attempts  to  enter 
the  bladder  with  a  soft  catheter.  If  this  succeeds,  as  it  may  very 
soon  after  the  injury,  before  urinary  extravasation  has  occurred, 
the  catheter  should  be  left  in  the  bladder  for  four  or  five  days,  while 
urinary  antiseptics  are  administered.  If  extravasation  of  urine  is 
already  present  when  the  patient  is  seen,  the  urethra  should  be  opened, 
immediately,  in  the  perineum,  with  the  aid  of  a  sound  passed  down 
to  the  site  of  rupture.  Numerous  incisions  in  the  perineum,  scrotum, 
and  skin  of  the  abdominal  wall  may  be  necessary  to  secure  free  drain- 
age and  avert  threatening  sepsis.  Usually  there  need  be  no  fear  that 
the  patient  will  be  unable  to  empty  the  bladder  through  the  wound, 
and  it  is  not  necessary  to  drain  the  bladder  by  a  catheter;  but  if  the 
vesical  end  of  the  urethra  is  readily  found  this  may  be  done.  In  a 
case  of  rupture  of  the  urethra  above  the  triangular  ligament  Demar- 
quay's  operation  (1858)  may  be  employed;  this  consists  in  dissect- 
ing down  to  the  site  of  rupture  through  a  curved  incision  (convexity 
forward)  as  in  the  modern  operation  of  perineal  prostatectomy  (p. 
1096).  Some  surgeons  advocate  suture  of  the  ruptured  urethra;  but 
in  all  the  cases  which  have  come  under  my  care,  the  local  condi- 
tion precluded  such  a  step.  When  the  perineal  wound  begins  to 
granulate,  it  is  usually  possible  to  pass  a  sound  through  the  penis 
into  the  bladder,  and  if  this  is  done  once  or  twice  weekly,  the  perineal 
wound  soon  closes.  The  danger  of  subsequent  stricture  formation, 
however,  is  very  great.  Traumatic  stricture  forms  rapidly  after  injury 
and  the  palliative  methods  and  even  the  usual  operations  employed 
for  stricture  the  result  of  gonorrhea  seldom  prevent  recurrence,  owing 
to  the  dense  nature  of  the  scar  and  its  extent.  Unless  the  patient 
can  have  bougies  passed  at  least  once  monthly  for  many  years  (perhaps 
throughout  life),  it  is  better  to  excise  the  strictured  area  and  to  unite 
the  healthy  urethra  above  and  below  by  sutures,  over  a  catheter 
which  is  left  in  place  for  several  days  or  until  the  urethral  wound  is 
healed.  I  employed  this  method  with  most  happy  results  in  the  case 
of  the  boy  shown  in  Fig.  1044.  Though  only  ten  years  old,  his 
urethra  easily  admitted  a  No.  18  Fr.  sound  one  year  after  operation. 
68 


1071  SURGERY  OF  THE  URETHRA   AND  PROSTATE 

Non-gonococcic  Urethritis  occasionally  occurs,  the  chief  causes 
being  instrumentation,  stricture,  ingestion  of  irritating  drugs,  excessive 
coitus,  or  masturbation,  etc.  If  the  condition  is  chronic  it  probably  is 
kept  up  by  a  stricture  or  a  focus  of  inflammation  in  the  prostatic 
urethra  or  its  adnexa.  The  acute  form  usually  subsides  so  soon  as 
the  cause  is  removed.  The  treatment  of  the  chronic  form  is  the  same 
as  for  chronic  gonococcic  urethritis  (p.  1068). 

Prolapse  of  the  Urethra  is  rare.  It  occurs  oftenest  in  female 
children,  from  straining  efforts  (coughing,  defecation,  micturition). 
The  protrusion,  which  seldom  involves  more  than  the  mucosa,  may 
be  excised,  and  bleeding  checked  by  pressure,  cauterization,  or 
suture. 

Stricture  of  the  Urethra. — Several  varieties  of  urethral  stricture  are 
recognized : 

I.  Inorganic  Strictures. — 1.  Inflammatory  Stricture,  or  obstruction  of 
the  urethra  from  acute  inflammation.  This  is  the  form  which  occa- 
sionally occurs  during  the  acute  stage  of  gonorrhea,  resulting  in  acute 
complete  retention  of  urine;  it  also  occurs  from  pressure  outside  the 
urethra,  from  an  inflamed  prostate,  periurethral  abscess,  etc.  It  is  to 
be  treated  by  palliative  measures  such  as  indicated  under  spasmodic 
stricture,  or  incision  and  drainage  through  the  perineum  of  prostatic 
or  periurethral  abscesses.  Introduction  of  a  catheter  should  be 
avoided  whenever  possible;  if  retention  persists,  the  bladder  may  be 
aspirated  above  the  pubis.  (2)  Spasmodic  Stricture:  This  is  no 
stricture  at  all,  merely  a  spasm  of  the  urethra,  though  it  occurs  most 
often  in  patients  with  organic  stricture.  It  occurs  also  as  the  result 
of  psychic  influence  (as  where  an  individual  cannot  urinate  in  the 
presence  of  others),  in  cases  of  inflamed  hemorrhoids  or  of  semino- 
vesiculitis,  after  surgical  operations,  in  the  course  of  the  infectious 
fevers,  etc.  Spasm  usually  occurs  in  the  membranous  urethra,  from 
the  contraction  of  the  deep  transversus  perinei  muscle.  If  retention 
is  complete,  and  of  eight  hours  or  more  duration,  a  catheter  should 
be  used;  if  incomplete  or  recent  palliative  measures  may  be  tried  for 
some  hours.  Among  the  most  effective  is  a  hot  bath,  the  patient 
attempting  to  urinate  in  the  bath ;  enemas  of  laudanum,  followed  by 
a  purge,  may  also  be  used.  Recurrence  of  spasm  must  be  prevented 
by  attending  to  the  condition  of  the  urine,  and  relieving  any  local 
cause,  especially  organic  stricture. 

II.  Organic  Strictures. — (1)  Traumatic  Stricture  has  been  described 
at  p.  1073.  (2)  Congenital  Stricture  is  less  rare  than  usually  supposed, 
but  may  produce  no  symptoms  until  the  age  of  puberty  or  later. 
(3)  Stricture  from  Cicatrices  folloiving  Urethritis,  almost  always  the 
result  of  gonorrhea,  is  the  type  most  often  seen,  and  what  is  said 
in  the  following  pages  refers  especially  to  it. 

Strictures  result  from  submucous  round-celled  infiltration,  which 
passes  through  the  usual  stages  of  organization,  cicatrization,  and 
contraction.  As  gonococcic  urethritis  is  most  frequent  about  the  age 
of  twenty  years,  strictures  are  seen  oftenest  in  early  adult  life;  they 


STRICTURE  OF  THE  URETHRA 


1075 


seldom  present  symptoms  for  the  first  time  after  forty  years  of  age. 
They  may  occur  in  any  portion  of  the  urethra,  but  are  most  frequent 
in  the  subpubic  portion,  especially  the  bulbous  urethra,  but  are  not 
rare  in  the  penile  urethra.  Stricture  of  the  membranous  and  prostatic 
urethra  is  rare.  Strictures  usually  are  multiple  (Fig.  1040),  and  may  be 
of  various  forms  (Fig.  1041).  Their  caliber  varies  from  that  which  is 
impassable  to  the  finest  instrument,  up  to  those  which  barely  con- 
strict the  urethral  lumen  and  which  may  be  detected  only  by  the 
aid  of  a  bulbed  sound.  The  orifice  of  the  stricture  may  be  central 
or  eccentric. 


Fig.  1040. — Strictures  of  the  urethra. 
A  probe  has  been  passed  through  a  false 
passage  in  the  bulbous  urethra.  (After 
Albarran.) 


Fig.  1041. — Diagram  of  different  forms 
of  stricture:  a,  annular;  b,  linear;  and  c, 
tortuous  stricture. 


Symptoms  and  Clinical  Course  of  Stricture.— The  early  symptoms  of 
stricture  usually  are  insignificant,  but  occasionally  acute  retention 
of  urine  is  the  first  indication  of  trouble.  In  most  cases  the  patient 
complains  first  of  slight  gleety  discharge,  with  pain  in  the  deep  urethra 
during  and  following  urination;  he  finds  the  calls  to  urinate  more 
frequent,  the  stream  is  diminished  in  size,  and  a  longer  time  is  required 
to  empty  the  bladder.  Attacks  of  acute  retention  are  frequent,  from 
inflammatory  changes  or  plugging  of  the  stricture  by  a  pellet  of  mucus 
or  pus.  Retention  with  overflow  is  another  frequent  sequel.  From 
straining  in  micturition,  hemorrhoids  or  prolapse  of  the  rectum  may 
develop.  The  urethra  immediately  behind  the  stricture  becomes 
dilated,  and  as  backward  pressure  continues,  changes  occur  in  the 


L076  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

bladder.  The  bladder  at  first  may  hypertrophy,  but  in  most  cases 
a  r<>  i  id  it  ion  of  atrophy  (fibroid  degeneration)  sets  in  eventually,  so  that 
the  bladder  loses  its  power  of  contraction.  This  is  predisposed  to  by 
cystitis,  which  is  prone  to  develop  (owing  to  stagnation  of  urine)  as 
the  result  of  instrumentation  or  as  a  descending  infection  from  the 
kidney.  Pressure  diverticula  may  form  in  the  bladder,  and  eventually 
dilatation  of  the  ureters  and  renal  pelves  may  occur,  with  hydrone- 
phrosis, pyonephrosis,  or  surgical  kidneys.  Other  complications  and 
sequels  are  frequent.  The  most  important  (Retention  of  Urine,  Ure- 
thral Fever,  Extravasation  of  Urine,  Periurethral  Abscess,  Urinary 
Fistulse)  are  discussed  in  the  following  pages. 

Diagnosis  of  Stricture. — While  the  existence  of  stricture  usually 
may  be  surmised  from  its  symptoms  enumerated  above,  or  from  its 
various  sequels,  verification  of  the  diagnosis  depends  on  instrumental 
examination  of  the  urethra.  The  caliber  of  the  normal  urethra  corre- 
sponds with  the  circumference  of  the  penis:  a  circumference  of  80  mm. 
implies  a  urethral  caliber  of  30  mm.  of  the  French  scale  (p.  1014);  85 
mm.  corresponds  to  32  Fr.;  90  mm.  corresponds  to  34  Fr.,  etc.  The 
a  re  rage  urethra  admits  a  No.  32  Fr.  sound,  but  the  meatus  usually  is 
smaller  than  the  urethra  within.  Strictures  of  large  caliber  are  best 
detected  by  passage  of  a  bulbed  sound.  Such  strictures  require  treat- 
ment only  if  productive  of  definite  symptoms.  Strictures  of  medium 
or  small  caliber  will  cause  the  arrest  of  an  ordinary  steel  sound  of 
average  size.  It  is  always  well  to  commence  the  examination  by 
passing  a  full  sized  sound,  and  then  to  try  smaller  sizes  in  turn  until 
one  is  passed  into  the  bladder.  It  is  not  safe  to  use  an  inflexible 
sound  smaller  than  No.  10  Fr.,  for  fear  of  making  a  false  passage. 

Treatment  of  Stricture. — There  are  two  main  classes  of  strictures, 
the  treatment  of  which  it  is  convenient  to  consider  separately:  these 
are  permeable  and  impermeable  strictures.  By  the  former  is  meant 
a  stricture  through  which  an  instrument  can  be  passed;  and  by  the 
latter  one  through  which  no  instrument  of  any  size  or  form  whatever 
can  be  passed.  This  distinction  is  relative,  since  a  stricture  which  a 
surgeon  finds  impermeable  on  one  occasion  may  not  be  so  on  another 
occasion  nor  for  another  surgeon. 

I.  Treatment  of  Permeable  Stricture.— 1 .  The  best  treatment 
is  that  by  gradual  dilatation.  A  sound  just  large  enough  to  be  grasped 
by  the  stricture  is  passed  about  twice  weekly,  and  the  size  of  the  sounds 
passed  is  very  gradually  increased.  Thus  if  No.  14  Fr.  has  been  passed 
with  a  little  difficulty  on  the  first  occasion,  it  is  well  to  begin  the  second 
seance  with  No.  12  Fr.,  and  not  to  push  dilatation  beyond  No.  16  Fr. 
At  the  third  sitting  Nos.  14,  16,  and  18  Fr.,  probably  can  be  passed. 
It  is  then  desirable  in  the  average  case  to  continue  dilatation  until 
a  number  on  the  scale  is  reached  which  is  two  or  three  points  higher 
than  that  which  is  considered  normal  for  that  patient.  But  in  the 
case  of  multiple  or  fibrous  strictures,  or  in  a  patient  who  is  old  or 
feeble,  or  prone  to  urinary  fever  or  other  complication,  it  is  best  to 
be  satisfied  with  keeping  a  canal  patulous  for  No.  22  or  24  Fr.    If 


TREATMENT  OF  STRICTURE  OF   THE   URETHRA        1077 

over-dilatation  can  be  secured  gradually,  and  if  it  can  be  maintained 
for  several  months,  it  is  probable  that  no  further  trouble  will  be  experi- 
enced. Absorption  of  the  cicatricial  tissue  will  have  occurred,  and 
unless  a  new  stricture  forms  the  patient  may  consider  himself  cured. 
In  cases  where  it  is  impossible  to  push  the  dilatation  up  to  normal 
and  beyond,  it  is  necessary  for  the  patient  to  have  a  sound  passed  once 
monthly  for  the  rest  of  his  life.  Neglect  of  this  precaution  will  allow 
the  stricture  to  recontract,  and  relief  of  the  patient  will  then  be  more 
difficult. 


Fig.  1042. — Kollman's  urethral  dilator.     (Watson  and  Cunningham.) 

2.  Treatment  by  rapid  dilatation  or  rupture  of  the  stricture  is,  I 
believe,  best  adapted  to  strictures  of  large  caliber,  such  as  sometimes 
cause  persistence  of  a  chronic  urethritis;  though  even  in  these  cases 
gradual  dilatation  often  is  sufficient.  Rupture  is  accomplished  by 
various  forms  of  instruments  which  are  first  passed  through  the 
strictures  and  then  expanded  by  some  mechanical  device  (Fig.  1042). 

3.  Incision  of  the  Stricture  (Urethrotomy)  is  the  best  treatment  for 
strictures  too  dense  and  fibrous  to  be  treated  successfully  by  gradual 
dilatation;  or  for  those  which  tend  persistently  to  recur,  even  after 
a  long  course  of  such  treatment.  But  it  should  never  be  forgotten 
that  it  may  be  more  judicious  to  persist  in  conservative  treatment 
in  the  old  and  feeble,  even  if  it  be  not  curative,  than  to  resort  even 
to  a  trivial  operation  which  may  suddenly  snuff  out  life. 


Fig.  1043. — 1.  Civiale's  urethrotome;  a  model  which  will  cut  the  stricture  from  behind 
forward,  or  from  before  backward.  2.  Syme's  grooved  staff  for  external  perineal  urethrot- 
omy.   3.  Tunnelled  catheter,  threaded  over  a  filiform  bougie. 

(a)  Internal  Urethrotomy  (Amussat,  1824)  is  especially  applicable  to 
strictures  of  the  penile  urethra:  it  is  accomplished  by  introducing 
an  instrument  through  the  stricture  and  then  withdrawing  from  the 
instrument  a  concealed  blade  (Fig.  1043,  1),  which  cuts  the  stricture 
on  the  roof  of  the  canal  from  behind  forward  (Civiale's  urethrotome, 


107S  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

L849)j  or  from  before  backward  (Maisonneuve's  urethrotome,  1855). 

The  operation  may  he  done  under  local  anesthesia  (10  per  cent. 
eucain),  but  a  general  anesthetic  is  preferable.  After  either  of  these 
operations  it  is  best  to  retain  an  inlying  catheter  for  three  or  four 
days,  the  penis  being  bandaged  to  it  if  there  is  much  hemorrhage 
(which  is  unusual);  and  after  the  catheter  is  removed,  dilatation 
must  be  maintained  by  passage  of  sounds  for  several  weeks,  or  longer 
if  a  tendency  to  recontraction  is  evident. 

(b)  External  Urethrotomy. — This  operation  is  safer  than  internal 
urethrotomy  for  strictures  in  the  deep  urethra.  It  was  popularized 
by  Syme  in  1843,  and  is  commonly  known  as  External  Perineal  Ure- 
throtomy with  a  Guide,  or  Sy??te,s  operation:  A  guide  is  passed  through 
the  stricture  from  the  meatus,  and  the  bulbo-membranous  urethra  is 
then  opened  from  the  perineum  upon  the  guide  behind  the  stricture, 
and  the  stricture  is  divided  from  behind  forward.  Syme  used  a  guide 
provided  with  a  groove  upon  its  convexity  and  a  shoulder  which 
rested  against  the  face  of  the  stricture  (Fig.  1043,  2).  After  division 
the  stricture  should  be  fully  dilated  by  passage  of  steel  sounds  and  the 
bladder  drained  by  a  perineal  tube  for  several  days,  when  the  passage 
of  sounds  may  be  commenced,  and  the  perineal  wound  allowed  to 
heal  by  granulation. 

II.  Treatment  of  Impermeable  Stricture. — Very  few  strictures 
are  really  impermeable;  indeed,  it  has  been  asserted  by  several  eminent 
authorities  that  any  stricture  which  would  permit  urine  to  escape  from 
above  would  also  admit  an  instrument  from  below.  But  as  their 
experience  increased  they  were  forced  to  acknowledge  that  they 
themselves  had  encountered  strictures  which  remained  impermeable 
to  their  best  efforts.  If  the  patient  is  able  to  pass  his  urine,  there 
is  plenty  of  time  available  for  attempts  to  render  the  stricture 
permeable.  Hence  it  is  convenient  to  discuss  the  treatment  of 
impermeable  stricture  according  as  it  is  not  or  is  accompanied  by 
retention  of  urine. 

1.  Impermeable  Stricture  unthoul  Retention  of  Urine. — The  first 
efforts  of  the  surgeon  should  be  devoted  to  rendering  the  stricture 
permeable.  It  is  not  safe  to  let  a  patient  with  impermeable  stricture 
continue  as  he  is;  the  risks  of  retention,  urinary  extravasation,  etc., 
are  too  imminent.  After  trying  the  usual  steel  sounds,  and  finding  it 
impossible  to  pass  the  stricture  with  any,  down  to  No.  10  Fr.  (no 
smaller  inflexible  instrument  is  safe)  the  surgeon  should  next  try  fine 
flexible  bougies  (those  filled  with  a  leaden  core  are  best)  which  on  account 
of  their  very  flexibility  may  be  enabled  to  pass  through  a  tortuous 
stricture  which  is  absolutely  impermeable  to  a  rigid  instrument.1  If 
such  an  instrument  cannot  be  passed  (even  a  No.  1  Fr.  may  be  used 
without  fear  of  damaging  the  urethra),  filiform  whalebone  bougies  should 
be  employed.  These  should  be  sterilized  in  the  same  way  as  the  flexible 
bougies  and  catheters,  in  a  cold  5  per  cent,  formalin  solution  (p. 

1  As  noted  at  p.  1014,  passage  of  a  bougie  usually  is  easier  after  distending  the 
urethra  with  the  lubricant  by  means  of  a  syringe. 


TREATMENT  OF  IMPERMEABLE  STRICTURE  OF  URETHRA  1079 

1014).  The  filiform  bougie  is  passed  down  to  the  face  of  the  stricture, 
where  it  may  be  arrested,  or  may  enter  a  false  passage  produced  by 
previous  instrumentation.  In  any  event  it  should  be  left  in  place, 
and  other  filiforms  should  be  passed  down  beside  it,  until  all  the  false 
passages  are  filled  and  the  face  of  the  stricture  is  covered  by  the  points 
of  the  bougies.  Then  as  the  last  filiform  is  introduced  it  may  slide 
at  once  through  the  stricture  and  into  the  bladder,  the  orifice  of  the 
stricture  being  the  only  point  unoccupied.1  Usually  not  more  than 
six  filiforms  are  introduced  at  once;  by  withdrawing  each  in  turn 
about  2  cm.  and  again  passing  it  down  against  the  face  of  the 
stricture  with  a  slight  twist,  the  surgeon  seeks  to  insinuate  one  of  the 
filiforms  into  the  orifice  of  the  stricture.  After  working  a  while  on  one 
side  of  the  patient's  bed,  it  sometimes  is  possible  to  accomplish  more 
by  passing  to  the  other  side  and  commencing  all  over  again,  as  the 
surgeon  insensibly  works  the  filiforms  toward  himself  on  whichever 
side  he  stands  (J.  H.  Brinton).  If  a  filiform  finally  is  passed  through 
the  stricture,  it  should  be  allowed  io  remain  in  place.  This  applies  to  any 
instrument  which  has  been  passed  through  a  stricture  with  great  diffi- 
culty. The  continuous  dilatation  of  the  stricture  thus  produced  will 
render  easier  the  later  passage  of  a  larger  instrument  (Fig.  1044).  "When 
a  filiform  has  been  successfully  passed  through  a  stricture,  all  the  other 
filiforms  may  be  withdrawn;  and  a  tunnelled  catheter  (popularized 
by  Gouley  about  1873)  may  be  passed  over  the  filiform  into  the  bladder, 
and  retained  in  place  of  the  filiform;  this  acts  as  rapid  dilatation  or 
rupture  of  the  stricture.  Some  filiforms  are  provided  with  a  cap  and 
screw  thread  at  their  outer  ends,  so  that  a  larger  bougie  may  be  screwed 
on  and  pushed  through  the  stricture  as  the  filiform  is  pushed  into  the 
bladder  where  it  curls  up. 

In  case  a  stricture  remains  impermeable  in  spite  of  repeated  efforts 
to  pass  an  instrument,  resort  must  be  had  to  operation.  As  in  this 
operation  no  guide  can  be  passed  through  the  stricture  (as  is  a  pre- 
requisite for  performing  Syme's  operation),  it  is  known  as  External 
Perineal'2  Urethrotomy  without  a  Guide,  or  Perineal  Section.3  Here  a 
sound  is  passed  down  to  the  face  of  the  stricture,  and  the  urethra 
is  opened  on  this  as  a  guide,  in  front  of  the  stricture,  by  an  incision 
through  the  perineum.  The  margins  of  the  opened  urethra  are  then 
caught  in  guy  sutures  and  pulled  taut,  while  the  surgeon  endeavors  to 
pass  a  probe  or  filiform  bougie  through  the  stricture  whose  face  is 
thus  exposed  to  view  (Arnott,  1822).  By  forcing  a  few  drops  of  urine 
out  of  the  bladder,  the  orifice  of  the  stricture  may  become  visible. 
If  a  probe  can  be  passed  through  the  stricture,  the  operation  is  com- 

1  If  an  endoscope  is  available,  it  may  be  possible  to  pass  a  filiform  through  the 
stricture  under  control  of  direct  vision. 

2  External  urethrotomy  scarcely  ever  is  necessary  for  strictures  of  the  penile 
urethra  because  these  very  rarely  are  impermeable;  but  it  may  be  employed  if 
requisite,  the  bladder  being  drained  by  an  inlying  catheter,  and  the  incision  in  the 
under  surface  of  the  penis  being  allowed  to  heal  by  granulation. 

3  Or  the  "old  operation,"  the  "London  operation"  (as  distinguished  from  the 
Edinburgh  operation,  or  Syme's). 


1080  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

pleted  as  in  Syme's  method,  by  dividing  the  stricture  on  the  guide. 
But  if  the  stricture  cannot  be  entered,  the  surgeon  proceeds  to  com- 
plete the  perineal  section,  dissecting  cautiously  backward,  strictly 
in  the  median  line,  until  he  has  divided  the  stricture  and  opened  the 
dilated  urethra  behind  it.  This  is  the  part  of  the  operation  which 
gives  it  the  name  of  perineal  section.1  It  is  an  operation  which  may 
prove  long  and  difficult,  but  with  a  good  light  and  steady  hand  it  is 
not  dangerous.  An  alternative  method  is  to  open  the  bladder  above 
the  pubis,  introduce  a  sound  into  the  vesical  orifice  of  the  urethra 
and  make  it  protrude  in  the  perineum  behind  the  stricture;  the  urethra 
is  then  opened  on  this  guide,  through  the  perineum,  and  the  stricture 
is  cut  from  behind  forward.  This  method  of  "retrograde  catheteriza- 
tion," I  regard  as  an  unnecessary  complication;  though  it  may  shorten 
the  operation,  it  does  not  lessen  its  mortality  or  improve  its  results, 


Fig.  1044. — Acute  complete  retention  of  urine  from  traumatic  stricture  of  urethra. 
Filiform  bougie  tied  in  the  urethra.  Age  nine  years,  injury  six  weeks  previously. 
Bladder  drained  itself  alongside  filiform  in  forty-eight  hours.  Treated  by  excision  of 
stricture      (See  p.  1073.)     Episcopal  Hospital. 

rather  the  reverse.  It  is  also  possible  to  open  the  urethra  at  the  apex 
of  the  prostate  (behind  the  stricture)  by  open  dissection  of  the  perineum 
(Guthrie,  1834;  Demarquay,  1858)  and  then  to  divide  the  stricture 
from  behind  forward;  or  to  perform  Cock's  operation  (p.  1081)  and  com- 
plete it  as  did  John  Hunter  (1788)  and  Guthrie  (1834)  by  division 
of  the  stricture  from  behind  forward.  But  the  best  operation  in 
impermeable  stricture  without  retention  of  urine,  is  the  perineal 
section,  as  systematized  by  Arnott  and  Jameson.  After  the  stricture 
has  been  cut  (by  whatever  method)  it  should  be  fully  dilated,  and  the 
bladder  drained  for  a  few  days  through  the  perineum. 

2.  Impermeable  Stricture  with  Retention  of  Urine.— Here  there  is 
no  time  for  long  delay.  There  is  danger  of  urinary  extravasation, 
rupture  of  the  bladder,  etc.,  and  uremia  generally  impends  from 

1  This  method,  according  to  Wiseman,  was  first  employed  in  1652  by  Molins; 
according  to  Guthrie  it  was  adopted  by  Sir  Astley  Cooper  in  1793.  The  operation 
was  systematized  by  Jameson,  of  Baltimore,  in  1824. 


URETHRAL  OR   URINARY  FEVER  1081 

renal  complications.  Not  more  than  thirty  minutes  should  be  spent 
in  attempts  to  pass  an  instrument  through  the  stricture;  if  a  filiform 
can  be  passed,  the  bladder  will  drain  itself  alongside  the  bougie  within 
twenty-four  to  forty-eight  hours  (Fig.  1044)  and  immediate  operation 
is  unnecessary.  If  no  instrument  can  be  passed,  and  if  the  bladder 
is  much  distended,  temporary  relief  may  be  secured  by  tapping  it 
suprapubically;  and  occasionally  after  the  bladder  is  emptied  the 
stricture  becomes  permeable.  In  many  cases,  however,  the  bladder 
is  thickened  and  contracted  from  cystitis,  and  is  not  accessible  above 
the  pubis;  and  even  if  it  is  possible  to  aspirate  it  in  this  position,  more 
permanent  drainage  is  required  than  can  be  secured  in  this  way.  Hence 
relief  of  retention  is  best  accomplished  by  Tapping  the  Urethra  at  the 
Apex  of  the  Prostate,  known  as  Cock's  operation.1  The  surgeon  intro- 
duces his  gloved  left  forefinger  into  the  rectum  and  places  it  upon  the 
apex  of  the  prostate.  Then  he  cuts  steadily  but  boldly  through  the 
median  line  of  the  perineum  toward  his  finger  as  a  guide;  when  the 
knife  is  felt  to  approach  the  finger,  it  is  made  to  cut  obliquely,  opening 
the  dilated  urethra  at  the  apex  of  the  prostate,  behind  the  stricture. 
The  knife  is  then  withdrawn,  and  a  grooved  director  takes  its  place, 
the  left  forefinger  being  kept  in  the  rectum  to  serve  as  a  guide  until 
the  director  is  in  the  bladder.  The  finger  is  then  withdrawn  from  the 
rectum,  and  the  glove  removed.  The  left  hand  then  holds  the  grooved 
director  while  the  right  hand  passes  a  catheter  along  it  into  the  bladder, 
where  it  is  retained  for  several  days.  After  this  lapse  of  time  the  stric- 
ture usually  becomes  permeable.  The  main  object  of  the  operation, 
as  I  recommend  it,  is  to  relieve  acute  complete  urinary  retention  in  cases 
of  impermeable  stricture.  When  the  patient  has  been  put  out  of  jeop- 
ardy by  this  means,  other  suitable  measures  may  be  adopted  to  cure 
the  stricture.  In  many  cases  it  is  feasible  to  follow  Hunter's  and  Guth- 
rie's advice,  and  complete  the  primary  operation  by  division  of  the 
stricture  from  behind  forward.  In  other  cases  the  patient  is  in  such 
desperate  condition  when  first  seen  that  any  prolongation  of  the 
operation  is  injudicious.  Cock's  operation  has  often  been  described 
as  "dramatic  in  its  simplicity,"  and  it  is  its  extreme  simplicity  and 
the  rapidity  with  which  it  may  be  done  that  commend  it. 

Urethral  or  Urinary  Fever  is  a  form  of  sepsis  due  to  absorption  of 
bacteria  or  their  products  from  erosions  or  abrasions  of  the  urethra. 
In  some  patients  it  is  a  frequent  sequel  to  the  passage  of  a  sound  or 
catheter.  Symptoms  usually  do  not  appear  until  after  the  first  act 
of  urination,  subsequent  to  the  instrumentation.  In  most  cases  there 
is  only  a  feeling  of  chilliness,  with  anorexia  or  nausea,  and  some  eleva- 
tion of  temperature;  but  there  may  be  a  frank  chill.  In  rare  cases  true 
pyemic  symptoms  develop,  with  acute  monarticular  or  polyarticular 
effusion. 

1  This  is  a  variety  of  the  old  bouttonniere  operation,  revived  in  1856  by  Mr. 
Cock,  of  Guy's  Hospital,  as  a  treatment  for  impermeable  stricture  complicated  by 
urinary  fistulce,  and  popularized  by  him  in  1866;  he  found  that  when  the  urine  was 
diverted  from  the  strictured  urethra  through  the  perineum,  the  fistuke  tended  to 
heal  spontaneously,  and  the  stricture  usually  became  permeable. 


1 1  iv  > 


SURGERY  OF  THE  URETHRA  AND  PROSTATE 


Treatment. — Treatment  consists  in  the  internal  use  of  urinary  anti- 
septics for  some  time  before  urethral  instrumentation,  and  the  admin- 
istration of  a  full  dose  of  quinine  and  opium  as  soon  as  the  instrumen- 
tation is  completed.  In  case  of  severe  and  recurrent  attacks,  it  may 
be  desirable  to  drain  the  bladder  by  the  perineum,  until  the  urethra 
becomes  healthier. 

Extravasation  of  Urine  lias  been  referred  to  (p.  1073)  as  a  complica- 
tion of  rupture  of  the  urethra,  and  its  clinical  features  were  pointed 
out  in  that  place.  It  occurs  not  infrequently,  also,  in  cases  of  urethral 
stricture,  either  spontaneously,  or  as  the  result  of  false  passages  made 
•by  careless  instrumentation.  That  false  passages  are  not  more  often 
accompanied  by  urinary  extravasation  is  no  doubt  attributable  to  the 
fact  that  the  false  passages  have  their  orifices  directed  away  from  the 
bladder.  Extravasation  of  urine  occurs  sometimes  in  cases  where  no 
stricture  exists.  One  of  the  worst  cases  I  ever  saw  was  in  an  old  man 
of  seventy-three  years,  in  whom  no  urethral  obstruction  existed, 
and  in  whom  no  instruments  had  been  passed.  In  such  cases  it  is 
probable  that  perforation  of  the  urethra  occurs  as  the  result  of  unrec- 
ognized ulceration  or  the  rupture  of  a  peri-urethral  abscess.  Treat- 
ment, as  already  advised,  consists  in  perineal  urethrotomy,  and  free 
incisions  wherever  required  to  drain  the  extravasated  urine  or  remove 
sloughs. 

Peri-urethral  Abscess. — Peri-urethral  abscess  was  mentioned  at  p. 
1005  as  a  complication  of  gonococcic  urethritis.  Usually  one  or  both 
Cowper's  glands  are  involved,  and  a  tender  swelling  appears  to  one 

side  or  other  of  the  median  raphe 
of  the  scrotum  at  its  junction  with 
the  perineum  (Fig.  1045).  The 
condition  is  distinguished  from 
perianal  or  ischio-rectal  abscess 
by  its  less  acute  symptoms,  the 
history  of  urethral  disease,  and 
the  location  of  the  swelling  in 
the  perineum  rather  than  close 
to  the  anus. 

Treatment. — Treatment  consists 
in  incising  the  abscess  as  soon  as 
it  is  recognized,  in  the  endeavor 
to  prevent  its  rupture  into  the 
urethra,  as^  this  latter  result 
almost  invariably  entails  the  sub- 
sequent formation  of  [alairinary 
fistula  in  the  perineum. 
Urinary  Fistulse. — Urinary  fistulse  usually  are  the  remote  result  of 
gonococcic  urethritis,  or  of  neglected  cases  of  extravasation  of  urine. 
Usually  the  fistula?  occur  in  the  perineum,  but  they  may  be  located 
in  the  scrotum,  in  the  penis  (floor  of  the  urethra),  in  the  adductor 
region  of  the  thighs,  or  in  the  buttocks.    In  almost  all  cases  the  com- 


Fig.  1045. — Peri-urethral  abscess,  on  the 
patient's  right.     Episcopal  Hospital. 


SURGERY  OF  THE  PROSTATE  1083 

munication  with  the  urethra  is  on  the  vesical  side  of  a  stricture,  and 
proper  treatment  of  the  stricture  often  allows  the  fistula?  to  close. 
In  cases  where  no  stricture  exists,  however,  and  especially  where  the 
fistula  is  indurated  and  lined  with  mucous  membrane,  it  is  necessary 
to  do  a  formal  operation.  The  use  of  an  inlying  catheter,  and  cauteriza- 
tion of  the  fistulous  orifices  seldom  is  efficient.  The  urethra  should 
be  drained  behind  the  internal  orifices  of  the  fistulse  by  Cock's  or  by 
Syme's  technique,  according  as  there  is  or  is  not  an  impermeable 
stricture;  a  stricture  if  present  should  be  cut;  and  the  fistulous  tracts 
should  be  excised,  and  if  possible  closed  by  suture.  Perineal  drainage 
of  the  bladder  may  be  dispensed  with  after  a  week  and  full  sized  sounds 
should  be  passed  regularly  until  the  fistulse  have  healed. 

SURGERY   OF   THE   PROSTATE. 

Acute  Prostatitis  and  Abscess  of  the  Prostate. — Usually  this  is  a 
complication  of  posterior  urethritis  (gonococcic),  involvement  occur- 
ring by  direct  extension.  In  rare  cases  acute  prostatitis  may  result 
from  the  trauma  of  frequent  or  careless  instrumentation;  and  occa- 
sionally prostatic  abscess  occurs  as  a  metastatic  infection  in  the 
course  of  the  exanthemas,  typhoid  fever,  pneumonia,  etc. 

Symptoms. — The  symptoms  are  both  general  and  local.  General 
symptoms  (high  fever,  typhoid  state,  muttering  delirium)  if  severe, 
may  completely  mask  the  local  condition,  which  causes  intense 
burning  pain  in  the  rectum,  with  rectal  tenesmus  and  usually  reten- 
tion of  urine.  Examination  by  a  finger  in  the  rectum  (extremely 
painful)  detects  the  enlarged  tender  prostate.  One  or  both  lobes  may 
be  involved.  Only  if  an  abscess  is  very  near  the  surface  can  a  soft 
area  or  fluctuation  be  detected  by  rectal  palpation. 

Treatment. — Treatment  should  be  palliative  at  first.  A  brisk 
purge  should  be  given,  and  the  urine  rendered  alkaline  (Watson). 
Some  relief  may  be  secured  from  hot  rectal  irrigations  and  sitz  baths. 
Urinary  antiseptics  should  be  administered,  and  if  there  is  urinary 
retention  it  is  better  to  allow  a  soft  catheter  to  remain  constantly 
in  the  bladder  than  to  pass  it  frequently.  Operation  should  be  done 
after  twenty-four  or  forty-eight  hours  unless  relief  is  obtained  sooner; 
but  if  suppuration  is  suspected  operation  should  be  immediate.  Only 
if  the  abscess  is  manifestly  pointing  in  the  rectum  should  it  be  opened 
by  this  route;  in  such  cases  a  drainage  tube  should  be  passed  within 
the  sphincter  ani,  but  need  not  enter  the  prostate.  Whenever  possible 
it  is  better  to  expose  the  prostate  as  in  perineal  prostatectomy,  incis- 
ing one  or  both  lobes  and  draining  the  retroprostatic  space  by  tube  or 
gauze.  Even  if  pus  is  not  found,  relief  is  prompt  and  lasting.  During 
convalescence  it  is  well  to  resort  to  regular  prostatic  massage. 

Chronic  Prostatitis — Chronic  prostatitis  is  a  still  more  frequent 
complication  of  posterior  urethritis  than  is  the  acute  form  of  the  dis- 
ease. Usually  it  is  gonococcic  in  origin,  but  as  a  rule  secondary  infec- 
tion has  occurred,  and  only  the  pyogenic  cocci  or  the  colon  bacillus 


KIM 


SURGERY  OF  THE   URETHRA  AND  PROSTATE 


can  he  found.  It  is  insidious  in  onset,  and  patients  may  not  come 
under  treatment  until  many  years  after  the  causative  urethritis  has 
ceased  to  cause  annoyance. 

Symptoms. — The  main  local  symptom  is  a  chronic,  gleety,  urethral 
discharge.  General  neurasthenic  symptoms  are  frequent,  and  referred 
pain  may  be  felt  in  the  back,  thighs,  buttocks,  groins,  etc.  The  diag- 
nosis is  confirmed  by  examination  of  the  rather  abundant  secretion 
obtained  by  massage  of  the  prostate  (p.  1069).  Soon  after  the  primary 
lesion  gonococci  or  other  bacteria  are  found;  but  at  later  periods  the 
secretion  is  composed  almost  entirely  of  pus  cells,  and  even  these 
may  not  be  found  until  after  massage  has  been  employed  for  the  third 
or  fourth  time. 

Treatment. — The  best  treatment  is  regular  prostatic  massage, 
about  three  times  weekly,  followed  by  urethral  and  vesical  irrigations, 
and  occasionally  by  instillation  of  5  per  cent,  silver  nitrate  or  the 
application  of  stimulating  ointments  to  the  deep  urethra.  The  use 
of  the  Kollman  urethral  dilator  (Fig.  1042,  p.  1077)  may  also  prove  of 
value. 


Fig.  1046. — Diagram  of  a  sagittal  sec- 
tion through  the  prostatic  urethra:  1. 
Sphincter  of  bladder  (internal) ,  posterior 
segment.  2.  Pre-spermatic  portion  of 
prostate.  3.  Ejaculatory  ducts.  4. 
Retro-spermatic  portion  of  prostate.  5. 
Urethra.  6.  Vesical  orifice  of  urethra. 
7.  Internal  sphincter  of  bladder,  anterior 
segment.  8.  Suburethral  or  paraureth- 
ral glands  (group  of  verumontanum) .  9. 
External  sphincter  of  the  bladder.  (After 
Cuneo.) 


Fig.  1047. — Diagram  of  a  sagittal  section 
of  the  prostatic  urethra,  in  a  case  of  "en- 
largement of  the  prostate:"  1.  Enlarge- 
ment (adenoma)  of  the  suburethral  glands 
(Fig.  1046,  8).  2.  Internal  sphincter  of 
the  bladder,  posterior  segment.  3.  Retro- 
spermatic  portion  of  the  prostate.  4. 
Ejaculatory  ducts.  5.  Pre-spermatic  por- 
tion of  prostate.  6.  Lateral  lobes  of 
tumor  (adenoma  of  suburethral  glands). 
7  External  sphincter  of  bladder.  8.  In- 
ternal sphincter  of  bladder,  anterior 
segment.  9.  Neck  of  bladder.  10. 
Bladder.    (After  Cuneo.) 


Enlargement  of  the  Prostate — This  often  is  spoken  of  as  hypertrophy 
of  the  prostate,  but  in  a  pathological  sense  there  is  no  true  hyper- 
trophy, and  I  prefer  to  retain  the  term  enlargement  simply  because 


ENLARGEMENT  OF   THE  PROSTATE 


1085 


the  actual  pathological  process  at  work  in  these  cases  is  still  in  dispute, 
and  because  it  is  the  mechanical  effect  of  the  enlargement  of  the 
gland  (urinary  obstruction)  which  makes  the  condition  important 
surgically.  The  modern  hypothesis,  put  forward  by  Motz  and  Pere- 
arnau  in  1905,  and  supported  by  researches  of  E.  Marquis  (1910) 
and  Cuneo  (1913),  is  to  the  effect  that  so-called  enlargement  of  the 
prostate  is  not  an  affection  of  the  prostate  at  all,  but  of  the  suburethral 
glands,  lying  beneath  the  urethra  immediately  on  the  vesical  side  of 
the  ejaculatory  ducts  (Fig.  1046).  According  to  this  theory,  the  change 
is  truly  neoplastic  (adenomyoma),  and  the  tumor  displaces  and  con- 
denses the  prostate  beneath  and  around  it  as  a  sort  of  capsule  (Figs. 
1047  and  1048).  Though  this  is  in  accord  with  the  facts  that  in 
"enlargement  of  the  prostate"  the  ejaculatory  ducts  are  depressed  far 
toward  the  rectal  aspect  of  the  tumor,  and  that  the  lengthening  of 
the  urethra  occurs  solely  in  that  portion  between  the  verumontanum 
and  the  bladder  (there  is  no  lengthening  of  the  segment  of  the  pros- 
tatic urethra  on  the  distal  side  of  the  verumontanum)  and  that  a 
few  years  after  "total  enucleation  of  the  prostate"  by  the  suprapubic 
route  palpation  reveals  what  is  apparently  a  normal  prostate  gland, 
nevertheless  this  theory  has  not  yet  gained  very  wide  acceptance. 

Clinically  there  are  two  seemingly  distinct  forms  of  enlargement 
of  the  prostate:  in  one  the  change  in  the  prostate  appears  to  be 
adenomatous  in  character,  and 
the  prostate  becomes  large,  soft, 
or  of  only  moderate  hardness; 
while  in  the  other  a  sclerosis 
exists,  as  if  caused  by  a  chronic 
inflammatory  process,  and  the 
prostate  does  not  become  very 
large.  I  believe  there  is  no 
good  evidence  that  this  fibrous 
type  of  enlargement  is  a  later 
stage  of  the  adenomatous  form, 
though  this  is  the  teaching  of 
Moullin  and  some  other  author- 
ities on  the  subject.  I  believe 
it  is  much  more  probable 
that  the    adenomatous  form  of 

enlargement  is  an  "adenomatosis'''1  of  the  prostate  (or  rather  of  the 
suburethral  glands),  or  even  a  true  adenomyoma;  while  the  small 
sclerotic  prostate  is  the  result  of  chronic  infection,  and  should  be  classed 
entirely  apart.  Ciechanowski  (1900)  and  others  since  his  time  have 
sought  to  show  that  all  cases  of  enlargement  of  the  prostate  were 
originally  inflammatory  in  origin,  the  main  causative  factor  being 
the  gonococcus. 

A  prostate  which  is  the  seat  of  the  adenomatous  type  of  enlarge- 
ment usually  presents  on  section  numerous  "prostatic  tumors"  which 
compress  the  surrounding  stroma  into  a  capsular  envelope,  and  which 


Fig.  1048. — Diagram  showing  in  transverse 
section  the  relation  of  the  periurethral 
adenoma  to  the  prostate:  1.  Capsule  of  the 
prostate.  2.  Urethra.  3.  Prostate,  com- 
pressed and  pushed  aside  by  the  new  growth. 
4.  Ejaculatory  ducts.  5.  Adenomyoma. 
(After  Cuneo.) 


L086  SURGERY  OF   THE   V RET II R A   AND  PROSTATE 

grow  in  the  direction  of  least  resistance  (toward  the  bladder) ;  here  they 
often  project  beneath  the  mucous  membrane  posterior  to  the  urethral 
orifice,  and  are  termed  (wrongly)  "median  lobe"  enlargements.  In 
some  cases  the  enlarged  prostate  presents  no  such  distinct  tumor 
masses  in  its  interior,  but  exhibits  general  glandular  or  fibrous 
enlargement,  or  a  combination  of  the  two  forms.  The  small,  hard, 
sclerotic  prostate  usually  is  densely  adherent  to  surrounding  struc- 
tures, and  these  evidences  of  former  peri-prostatitis  lend  support  to  the 
view  that  such  prostates  have  been  altered  by  chronic  inflammatory 
changes. 

Any  prostate  weighing  more  than  23  grams  may  be  considered  abnor- 
mal. From  this  size  they  range  up  to  400  grams  or  more.  The 
average  weight  of  prostates  removed  at  operation  is  less  than  100 
grams.  Enlargement  occurs  chiefly  in  an  anteroposterior  direction 
and,  as  the  apex  of  the  prostate  is  fixed  against  the  triangular 
ligament,  growth  occurs  chiefly  toward  the  vesical  cavity.  The  two 
lateral  lobes  usually  are  not  equally  enlarged,  and  this  accounts  for  a 
rather  constant  deviation  of  the  urethra  to  one  or  other  side.  The 
two  lateral  lobes  may  project  into  the  bladder  in  such  a  form  that 
the  urethral  orifice  resembles  the  os  uteri;  or  as  already  mentioned, 
a  "prostatic  tumor"  may  force  its  way  through  the  capsule  of  the 
prostate  and  project  beneath  the  vesical  mucous  membrane  as  a 
nipple-like  obstruction  or  as  a  pedunculated  out-growth  behind  the 
vesical  orifice  of  the  urethra. 

Clinical  Pathology. — As  the  prostate  gland  enlarges,  various  changes 
are  produced  in  the  urethra,  bladder  and  rectum;  and  less  directly 
in  the  urine,  kidneys,  and  general  health. 

Changes  in  the  Urethra. — The  length  of  the  normal  urethra  averages 
20  cm.;  but  in  enlargement  of  the  prostate  the  length  may  be  35  or 
40  cm.,  the  increase  occurring  in  the  prostatic  portion  of  the  canal, 
especially  in  that  portion  on  the  vesical  side  of  the  ejaculatory  ducts. 
This  fact  also  explains  the  elevation  of  the  vesical  orifice  of  the  urethra 
and  the  increased  curve  of  the  prostatic  urethra,  necessitating  a  special 
curve  to  inflexible  instruments  (Fig.  1049,  3  and  4).  Lateral  deviation 
of  the  urethra  has  been  mentioned  above.  In  some  cases  a  peduncu- 
lated enlargement  at  the  vesical  orifice  produces  a  Y-shaped  channel. 
Increase  in  length  of  the  posterior  wall  of  the  prostatic  urethra  may 
increase  its  antero-posterior  diameter  and  consequently  its  capacity, 
so  that  it  may  hold  25  to  50  c.c.  of  urine;  this  is  rare,  but  should 
be  remembered  as  a  possibility,  since  evacuation  of  a  small  amount 
of  urine  from  the  dilated  prostatic  urethra  may  lead  the  inexperienced 
to  think  the  catheter  has  entered  the  bladder. 

The  most  important  change  in  the  bladder  is  the  formation  of  a 
post-prostatic  pouch,  due  to  combined  elevation  of  the  urethral  orifice 
and  descent  of  the  vesical  floor.  The  greater  the  obstruction  to  the 
outflow  of  urine  the  larger  this  pouch  becomes,  and  the  more  residual 
urine  collects  in  it.  Residual  urine  is  that  which  remains  in  the  bladder 
after  the  patient  has  expelled  all  he  can.    At  first  some  hypertrophy 


ENLARGEMENT  OF   THE  PROSTATE  1087 

of  the  vesical  walls  may  occur,  but  if  obstruction  is  unrelieved  dilata- 
tion and  atrophy  ensue,  and  the  quantity  of  residual  urine  gradually 
increases.  This  state  of  chronic  incomplete  retention  of  urine  without 
distention  of  the  bladder  (stage  of  residual  urine)  is  finally  succeeded 
by  the  same  condition  with  distention  of  the  bladder,  and  when  the 
limit  of  the  bladder's  capacity  has  been  reached,  overflow  occurs 
(retention  with  overflow).  The  distinction  between  the  latter  condition 
and  true  incontinence  of  urine  has  been  explained  at  p.  (345.  But 
cystitis  may  occur,  and  then  the  bladder  does  not  dilate;  its  walls 
become  thickened  and  its  capacity  diminished.  Vesical  irritability 
demands  frequent  evacuation,  and  retention  with  overflow  is  rare. 
The  adenomatous  type  of  enlargement  usually  is  associated  with  a 
dilated  bladder;  while  where  cystitis  and  contraction  of  the  bladder 
are  present  the  prostate  usually  is  small  and  fibrous. 

The  effects  on  the  kidneys  and  ureters  are  those  usual  in  other  cases 
of  urinary  obstruction,  with  or  without  infection  (p.  1029). 

The  residual  urine  almost  invariably  becomes  alkaline,  and  invites 
the  occurrence  of  cystitis,  but  if  acute  retention  does  not  occur, 
and  catheterization  is  avoided,  the  occurrence  of  cystitis  may  be  long 
postponed.  Phosphatic  calculi  frequently  form,  but  as  they  are  more 
or  less  fixed  in  the  retroprostatic  pouch  may  cause  no  characteristic 
symptoms. 

Effects  on  Urination. — Residual  urine  diminishes  the  capacity 
of  the  bladder;  hence  urination  must  be  more  frequent.  Frequent 
urination  increases  the  existing  congestion;  this  in  turn  may  bring 
on  retention  of  urine;  catheterization  is  resorted  to,  once  or  oftener, 
and  cystitis  is  the  usual  consequence.  The  retention  and  the  infection 
produce  nephritis,  the  quantity  of  urine  is  increased,  and  this  causes 
still  more  frequent  calls  to  evacuate  the  bladder.  In  this  way  a  vicious 
circle  is  produced,  and  unless  the  original  cause  of  all  this  woe,  uri- 
nary obstruction,  is  removed,  the  patient's  general  health  quickly 
deteriorates.  Dilatation  of  the  bladder  and  changes  in  its  walls  cause 
feeble  power  of  expulsion,  and  slowness  in  completing  the  urinary 
act;  while  the  inability  of  the  vesical  neck  to  act  properly  and  the 
interference  with  the  action  of  muscles  around  the  membranous  urethra 
cause  the  last  portions  of  urine  to  be  voided  in  dribbles,  no  power 
remaining  of  evacuating  it  in  spurts. 

Effects  on  the  Rectum. — The  rectum  may  be  obstructed  by  an 
enlarged  prostate,  causing  increasing  difficulty  in  defecation;  and  the 
constant  straining  in  micturition  is  a  frequent  cause  of  hemorrhoids 
and  prolapsus. 

Symptoms  and  Clinical  Course. — Symptoms  seldom  are  observed 
before  the  age  of  fifty  years,  but  usually  enlargement  is  present  for 
some  time  before  notable  symptoms  are  produced.  Usually  the 
disease  is  insidious  in  onset,  and  the  first  abnormality  noted  is  noc- 
turnal frequency  of  urination.  Urination  probably  is  as  frequent  by 
day,  but  does  not  arrest  attention.  Sometimes  involuntary  dribbling 
of  urine  is  the  first  sign  of  trouble,  usually  due  to  retention  with  over- 


1088  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

flow.  Occasionally  acute  retention  is  the  first  symptom.  Starting 
the  stream  is  difficult,  because  there  is  both  increased  obstruction  to  be 
overcome,  and  decreased  expulsive  power;  the  stream  tends  to  drop 
vertically  from  the  meatus;  a  longer  time  than  usual  is  required  to  pass 
the  urine,  though  the  amount  evacuated  each  time  may  be  small; 
and  the  urine  dribbles  at  the  end  of  the  act  of  urination.  Retention  of 
urine  is  noticed  by  the  patient  only  when  acute,  or  when  the  chronic 
form  is  accompanied  by  overflow.  The  symptoms  of  cystitis  and  renal 
complications  need  not  be  detailed  here.  Hematuria  seldom  occurs 
spontaneously,  but  may  follow  the  most  gentle  catheterization,  from 
rupture  of  varicose  urethral  or  vesical  veins. 

Patients  with  enlarged  prostates  may  be  divided  roughly  into  three 
classes  (Deaver  and  Ashhurst,  1905) :  in  the  earliest  stage  the  chief 
complaint  is  nocturnal  frequency  of  urination;  in  the  second  stage 
patients  suffer  occasionally  from  complete  retention,  but  are  not  much 
troubled  by  cystitis  and  enjoy  fairly  good  health;  while  in  the  third 
stage  urinary  retention  is  nearly  absolute,  the  bladder  cannot  be  evac- 
uated without  a  catheter,  the  kidneys  are  markedly  diseased,  and  the 
patients  are  on  the  verge  of  the  grave. 

Diagnosis. — Diagnosis  of  enlargement  of  the  prostate  cannot  be 
made  from  the  symptoms  alone;  physical  examination  is  required. 
The  first  and  most  important  sign  to  be  looked  for  is  a  distended 
bladder;  neglect  to  observe  this  sign,  and  the  hasty  and  injudicious 
introduction  of  a  catheter  in  cases  of  long  standing  retention  with 
overflow  may  cause  immediate  syncope  (from  decrease  of  intra- 
abdominal pressure),  and  may  lead  in  a  few  days  to  the  patient's 
death  from  renal  congestion  and  uremia.  The  proper  treatment  of 
retention  with  overflow  is  given  at  p.  1091.  Having  noted  the  absence 
of  a  distended  bladder,  request  the  patient  to  pass  all  the  urine  he 
can,  and  note  the  facility  with  which  he  starts  the  stream,  the  force 
with  which  it  is  expelled,  and  the  presence  or  absence  of  dribbling 
at  the  end  of  urination.  The  amount  of  urine  passed  should  be  meas- 
ured, and  the  habitual  frequency  of  urination  noted.  A  patient  who 
passes  100  c.c.  of  urine,  more  or  less,  every  two  hours,  probably  has 
no  serious  renal  lesion.  If  he  passes  100  c.c.  only  every  three  or 
four  hours,  either  the  normal  amount  is  not  excreted  by  the  kid- 
neys or  the  quantity  of  residual  urine  is  rapidly  increasing.  If, 
on  the  other  hand,  15  or  30  c.c.  is  passed  every  ten  or  fifteen  minutes, 
the  kidneys  will  be  excreting  from  1£  to  4|  liters  of  urine  daily, 
and  retention  with  overflow  probably  exists.  If  the  bladder  is  not 
distended,  the  surgeon  should  next  insert  a  catheter,  to  ascertain  the 
quantity  of  residual  urine.  For  diagnostic  purposes  (not  for  treat- 
ment by  catheterism,  p.  1089)  I  prefer  a  metallic  instrument,  since  it 
acts  also  as  an  exploratory  sound.  As  this  is  passed,  note  the  presence 
or  absence  of  strictures,  any  deviation  of  the  subpubic  urethra,  the 
height  to  which  the  vesical  orifice  is  raised,  and  the  distance  from  the 
external  urinary  meatus  at  which  urine  begins  to  flow.  The  following 
facts  favor  the  diagnosis  of  enlarged  prostate:  if  the  shaft  has  to  be 


ENLARGEMENT  OF  THE  PROSTATE  1089 

depressed  unduly  between  the  patient's  thighs  before  urine  flows, 
indicating  elevation  of  the  vesical  orifice  of  the  urethra;  if  the  urinary 
distance  (that  from  the  meatus  to  the  point  at  which  urine  commences 
to  flow)  is  increased  above  20  cm.;  if  the  catheter  deviates  laterally 
in  the  prostatic  urethra;  or  if  the  catheter  meets  an  obstruction  more 
than  18  cm.  from  the  meatus,  showing  the  obstruction  is  further 
back  than  the  usual  site  of  strictures.  A  small  amount  of  urine 
evacuated  from  the  dilated  prostatic  urethra  should  not  deceive  the 
examiner  into  thinking  the  bladder  has  been  reached. 

The  amount  and  character  if  the  residual  urine  are  now  noted;  and 
finally  a  few  ounces  of  saline  solution  are  injected  into  the  bladder, 
and  the  metal  catheter  is  used  very  gently  as  a  sound  to  explore  the 
condition  of  the  vesical  walls  and  to  search  for  calculi  in  the  post- 
prostatic  pouch.  Before  the  catheter  is  removed,  insert  a  finger  into 
the  rectum  and  palpate  the  prostate;  the  intravesical  instrument 
can  then  be  regarded  as  a  very  long  finger,  and  the  prostate  can  be 
palpated  between  this  and  the  finger  in  the  rectum. 

Treatment. — This  may  be  discussed  under  the  headings:  (1)  General 
treatment;  (2)  palliative  treatment,  which  includes  catheterism  and  cer- 
tain palliative  operations;  and  (3)  radical  treatment  by  prostatectomy. 

1.  General  Treatment  is  important.  Especial  attention  should  be 
paid  to  diet,  to  hygiene,  and  to  securing  free  evacuation  of  the  bowels. 
Cascara  or  some  similar  laxative  is  to  be  preferred.  Atropin  never 
should  be  given  long  at  a  time,  for  fear  of  increasing  vesical  atony; 
hence  the  popular  A.  B.  &  S.  pills  should  be  avoided.  The  urine 
should  be  kept  acid,  by  administration  of  benzoic  acid  in  0.30  gram 
doses,  with  twice  the  quantity  of  sodium  bicarbonate  to  ensure 
solution;  and  if  the  urine  is  not  too  acid  urotropin  is  the  best  anti- 
septic. For  excessively  acid  urine  it  is  best  to  increase  the  ingested 
fluid,  to  decrease  the  sugars,  and  to  administer  alkaline  salts  of 
potassium  or  sodium. 

2.  Palliative  Treatment. — Catheterism  consists  in  periodical  evac- 
uation of  the  residual  urine  by  use  of  a  catheter.  This  will  cure  no 
patients,  but  may  promote  their  comfort,  and  in  the  very  aged  or 
feeble  may  even  prolong  life.  As  the  expectation  of  life,  however, 
in  patients  treated  by  catheterism  is  in  the  average  no  more  than  four 
or  five  years,  it  is  clear  that  the  life  of  the  average  patient  is  shortened 
by  such  treatment.  I  do  not  recommend  it  except  when  prostatectomy 
is  contraindicated.  The  frequency  of  catheterization  depends  entirely 
upon  the  distress  occasioned  by  residual  urine,  provided  the  latter  is  not 
increasing  in  quantity.  As  a  general  rule  a  patient  with  125  c.c.  of 
residual  urine  requires  to  be  eatheterized  once  in  twenty-four  hours; 
the  best  time  is  just  before  going  to  bed.  If  200  c.c.  are  present,  use 
the  catheter  twice,  night  and  morning,  and  add  one  more  catheteri- 
zation for  each  additional  GO  c.c.  of  urine  up  to  six  times  daily. 
When  the  required  number  of  catheterizations  exceeds  this  limit, 
some  other  form  of  treatment  is  urgently  demanded,  even  though 
catheterism  appears  to  maintain  the  patient's  general  health. 

69 


1090  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

Catheters  for  use  in  discs  of  enlarged  prostate  should  be  •'>.">  to  40  cm. 
long.  If  there  is  difficulty  in  introducing  the  usual  soft  rubber  catheter, 
it  is  possible  usually  to  insert  a  Merrier  catheter;  this  is  one  made  of  web- 
bing, like  the  English  catheter  (p.  1013),  but  having  the  point  set  at  an 
angle  of  1 10  degrees  with  the  shaft  (Fig.  1040, 1 ) .  This  elbow  facilitates 
the  point  of  the  catheter  riding  over  the  prostatic  obstruction,  the 
point  of  the  instrument  being  made  to  follow  the  roof  of  the  urethra. 
A  double  elbowed  catheter  may  be  useful  at  times.  If  neither  of  these 
can  be  inserted,  an  English  catheter,  moulded  to  the  proper  "prostatic 
curve,"  as  advised  at  p.  1014,  may  be  used.  If  it  will  not  pass  without 
the  stylet,  it  should  be  reintroduced  with  the  over-curved  stylet  in  its 
interior;  when  the  obstruction  is  met,  the  stylet  may  be  withdrawn 
about  2  cm.,  thus  raising  the  point  of  the  instrument  over  the  ob- 
struction (Physick,  1818)  (Fig.  1049,  3).  A  metal  prostatic  catheter 
is  advisable  only  where  the  tissues  are  so  hard  and  resistant  from 
long-standing  inflammation,  that  flexible  instruments  are  not  strong 
enough  to  push  apart  the  sclerosed  structures.  If  the  patient  has  to 
catheterize  himself  a  metal  catheter  never  should  be  allowed;  the  best 
instrument  is  the  soft  rubber  catheter,  next  the  Mercier  or  the  Eng- 
lish. The  patient  should  be  drilled  frequently  in  the  necessary  aseptic 
technique,  care  of  the  catheters,  and  their  introduction.  Only  intel- 
ligent and  careful  patients,  willing  to  devote  the  necessary  time  to 
the  matter,  will  succeed  in  avoiding  the  prompt  occurrence  of  cystitis, 
which  is  eventuallv  nearly  inevitable. 


Fig.  1049. — Prostatic  catheters:  1.  Mercier's  coude  (elbowed)  catheter.  2.  Bi-coude, 
or  double  elbowed  catheter.  3.  English  catheter  mounted  on  an  over-curved  stylet; 
when  the  stylet  is  partly  withdrawn  the  catheter  assumes  the  form  indicated  by  the 
dotted  lines.     4.   Metal  catheter,  with  prostatic  curve. 

Besides  the  occurrence  of  cystitis,  the  treatment  of  which  is  dis- 
cussed at  p.  1018,  certain  other  complications  are  not  unusual.  Acute 
complete  retention  of  urine  is  treated  by  immediate  catheterization. 
There  is  great  danger  in  delay,  and  the  chance  of  the  retention  being 
overcome  by  palliative  measures  is  very  much  less  than  in  cases  of 
acute  retention  from  stricture.  In  chronic  complete  retention  of  urine 
the  bladder  should  be  drained  by  a  permanent  catheter,  in  the  hope 
that  the  cause  is  atony  of  the  bladder,  which  may  be  relieved  by  con- 
stant drainage.  If  retention  persists  after  atony  has  been  relieved  in 
this  way,  or  if  atony  is  not  relieved  by  the  drainage,  it  will  be  advisable 


ENLARGEMENT  OF   THE  PROSTATE  1091 

either  to  remove  the  prostate  or  to  establish  a  suprapubic  vesical 
fistula  (see  below).  The  treatment  of  residual  urine  (chronic  incom- 
plete retention  of  urine,  without  distention  of  the  bladder)  has  been 
considered  at  p.  1089.  Finally  there  may  be  retention  with  overflow 
(chronic  incomplete  retention  of  urine  with  distention  of  the  bladder) : 
here  immediate  and  complete  withdrawal  of  the  urine  from  the  bladder 
is  considered  inadvisable,  since  experience  has  shown  that  sudden 
relief  of  intravesical  pressure  usually  is  followed  by  hematuria  from 
rupture  of  veins  in  the  bladder  walls,  and  is  frequently  followed  by 
the  development  of  surgical  kidneys,  uremia,  coma,  and  death,  within 
a  few  days.  It  is  probable  that  the  danger  in  such  cases  lies  in  the 
intermittent  catheterization  that  has  usually  been  employed,  since 
this  increases  the  chances  of  infection,  and  since  Cabot  (1903)  showed 
that  constant  drainage  by  the  use  of  an  inlying  catheter  was  able  to 
avert  threatening  fatalities  from  such  causes.  Hence  the  surgeon 
either  should  adopt  Cabot's  plan  or  should  adhere  to  the  time-honcred 
custom  of  evacuating  such  over-distended  bladders  by  degrees,  with- 
drawing only  about  100  c.c.  at  a  time;  or  if  all  the  urine  is  drawn 
at  once,  and  an  inlying  catheter  is  not  retained,  he  should  replace 
most  of  the  fluid  withdrawn  from  the  bladder  by  saline  solution. 

Among  palliative  operations  the  formation  of  a  suprapubic  fistula 
holds  first  place.  This  was  popularized  in  1888  by  Hunter  McGuire; 
the  operation  resembles  that  of  suprapubic  cystotomy  (p.  1025). 
Where  urethral  obstruction  is  marked,  there  is  no  likelihood  of  the 
suprapubic  fistula  closing,  but  when  this  tendency  is  observed  a  rubber 
tube  should  be  worn  constantly  in  the  fistula.  At  the  time  of  the 
operation  any  calculi  present  may  be  removed,  but  no  attempt  should 
be  made  to  remove  the  prostate  in  such  feeble  patients  as  those  for 
whom  this  palliative  operation  is  advisable.  Siter  (1912),  however, 
has  found  that  dilatation  of  the  vesical  orifice  of  the  urethra,  by  the 
insertion  of  the  surgeon's  finger  through  the  suprapubic  wound,  may 
secure  almost  as  much  relief  (even  if  only  temporary)  as  a  formal 
prostatectomy,  and  may  be  resorted  to  without  materially  prolonging 
the  operation  or  increasing  its  gravity.  If  a  pedunculated  prostatic 
out-growth  is  found  acting  as  a  ball-valve  against  the  vesical  orifice 
of  the  urethra,  it  should  be  removed ;  if  no  other  urethral  obstruction 
exists  (a  point  readily  determined  by  passing  a  soft  catheter)  this 
may  effect  permanent  relief  of  all  symptoms.  In  some  cases  where 
the  prostate  is  small  and  atrophic,  and  the  bladder  thickened  and 
contracted,  much  relief  may  be  secured  by  median  perineal  cystotomy, 
with  incision  of  the  prostate  and  dilatation  of  the  prostatic  urethra 
(perineal  prostatotomy) ;  a  perineal  tube  is  retained  until  a  permanent 
fistula  is  assured.  After  either  suprapubic  or  perineal  drainage  a  fair 
measure  of  continence  is  secured;  and  constant  drainage  by  an  in- 
lying catheter  will  be  available  whenever  demanded  by  the  occurrence 
of  cystitis. 

The  Bottini  operation  was  introduced  in  1874,  but  little  used  until 
popularized  by  Freudenberg  in  1897.    It  consists  in  making  incisions 


1 1  !!>•_' 


SURGERY  OF  THE   URETHRA  AND  PROSTATE 


in  the  prostate  by  a  galvano-cautery  introduced  through  the  urethra. 
The  subsequent  cicatrization  and  contraction  of  these  incisions  may 
reduce  the  size  of  the  prostate  and  thus  overcome  urinary  obstruction; 
or  they  may  fail  to  do  so.  The  operation  is  uncertain  in  its  results, 
the  good  effects  sometimes  secured  are  not  permanent,  and  the  mor- 
tality is  no  lower  than  that  of  prostatectomy  in  skilled  hands. 

3.  Radical  Treatment  consists  in  removal  of  the  prostate.  It  is 
the  treatment  of  choice,  and  should  be  adopted  in  every  case  except 
where  distinct  contraindications  exist.  The  chief  contraindications 
are  severe  cystitis  and  renal  insufficiency;  and  these  usually  may  be 


Peritoneum 


oneurosis  °//}enonvii/iers 
0/) 


Prostate 
Ant.  layer  °f  Triangular  ligament 
Post,  lai/er  °J 'Triangular  ligament 


Fig.  1050. — Sheath  of  prostate  in  sagittal  section  (diagrammatic).     (Deaver  and 

Ashhurst.) 

overcome  by  preliminary  treatment,  which  may  include  some  of  the 
palliative  operations  already  discussed,  notably  suprapubic  drainage 
of  the  bladder.  Extreme  age  is  not  a  contraindication1,  but  if  such 
patients  can  be  kept  comfortable  by  catheter  life,  it  will  not  be 
advisable  to  resort  to  prostatectomy. 

Two  methods  of  operation  are  in  common  use:  the  siqyrapubic, 
introduced  in  1887  by  McGill  of  Leeds,  and  improved  and  popularized 
in  1901  by  Freyer,  of  London;  and  the  perineal,  which  was  a  gradual 


1 1  have  resorted  successfully  to  suprapubic  prostatectomy  in  a  patient  in  his 
eighty-ninth  year. 


PROSTATECTOMY 


1093 


development  of  the  practice  of  perineal  prostatotomy  (a  common 
practice  in  the  early  part  of  the  last  century),  and  which  was  employed 
first  in  cases  of  malignant  disease  during  the  decade  from  1870  to 
1880.  Its  modern  development  is  due  largely  to  the  labors  of  the 
French  school,  headed  by  Albarran,  and  to  its  exploitation  in  this 
country  by  Dr.  H.  H.  Young,  of  Johns  Hopkins  University. 

jecto-vesica?  fascia  <r^*^ 
,/st.  Division   s*—-^    J  \ 
,2  nd.  Division  ^r     J 
,  3rd.  Division  ^ 


Ohfurafor 
Intemi/.s 

Anal  fascia- 
Leva  for  A?ii  - 


Int.Fudic 

vessels  &  nerve: 


Fig.  1051. 


-Sheath  of  prostate  in  transverse  section.     Line  of  section  shown  in  the 
lower  drawing  (diagrammatic.)     (Deaver  and  Ashhurst.) 


For  cases  of  enlarged  prostate  of  the  adenomatous  type  (the  immense 
majority)  suprapubic  prostatectomy  (Freyer)  is  preferable;  but  where 
the  prostate  is  dense,  and  adherent  to  surrounding  structures,  and 
where  the  bladder  is  small  and  contracted,  the  operation  is  best  done 
through  the  perineum,  as  it  will  be  impossible  to  shell  out  the  organ 
as  in  the  suprapubic  operation. 


109  I  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

Suprapubic  Prostatectomy. — The  prostate  lies  upon  the  triangular 
ligament  and  above  the  aponeurosis  of  Denonvilliers  (Fig.  1050); 
neither  of  these  structures,  so  important  in  completing  the  floor 
of  the  pelvis,  is  divided  when  the  prostate  is  lifted  off  them  and 
delivered  into  the  cavity  of  the  bladder.  When  the  prostate  is  adeno- 
matous its  enucleation  in  this  manner  is  accomplished  with  surprising 
ease.  The  enlarged  prostate  projects  into  the  bladder,  and  is  covered 
only  by  mucous  membrane  or  at  most  by  attenuated  muscular  tissue 
which  is  as  much  prostatic  capsule  as  it  is  vesical  wall.  Enucleation 
takes  place  theoretically  between  the  proper  prostatic  capsule  (con- 
densed by  the  eccentric  enlargement  of  the  "prostatic  tumors") 
and  its  sheath,  formed  by  partitions  of  the  rectovesical  fascia  (Fig. 
1051).    It  is  not  unlikely,  however,  that  in  many  cases  the  enucleation 


Fig.  1052. — Suprapubic  prostatectomy. 

takes  place  within  the  layers  of  the  true  prostatic  capsule,  much  as  the 
heart  of  an  onion  may  be  shelled  out,  leaving  the  outer  layers  intact. 
The  bladder  is  opened  as  in  suprapubic  cystotomy  (p.  1025),  and  to 
assist  subsequent  manipulations  the  index  and  middle  fingers  of  one 
hand  (gloved)  are  passed  into  the  patient's  rectum  (the  sphincter  hav- 
ing been  well  stretched  previously)  and  are  made  to  push  the  prostate 
up  toward  the  suprapubic  wound  (Fig.  1052).  The  surgeon  then  inserts 
a  finger  of  the  other  hand  into  the  vesical  orifice  of  the  urethra,  and 
breaks  through  the  mucous  membrane  covering  the  enlarged  prostate. 
The  natural  line  of  cleavage  is  found  without  much  trouble.  The 
finger  should  first  pass  to  the  outer  side  of  the  lateral  lobe  first  attacked, 


SUPRAPUBIC  PROSTATECTOMY  1095 

since  here  the  attachment  of  the  prostate  to  its  sheath  is  least  dense. 
Then  the  finger  cautiously  but  not  timidly  works  down  under  the 
lateral  lobe  toward  the  neighborhood  of  the  posterior  commissure 
and  the  ejaculatory  ducts.  Next  the  posterior  and  inferior  surfaces 
are  separated  from  the  sheath;  and  finally  when  the  lobe  is  pretty  well 
outlined  the  finger  may  pass  along  the  lateral  and  inferior  surfaces 
to  the  apex  of  the  lobe  and  free  this  from  the  triangular  ligament. 
At  times  the  lateral  lobe  first  attacked  comes  away  alone,  leaving 
the  urethra  still  attached  to  the  other  lobe.  More  often  the  vesical 
mucous  membrane  tears  during  this  enucleation,  and  the  vesical 
orifice  of  the  urethra  becomes  entirely  detached  by  extension  of  the 
tear  across  the  trigone  of  the  bladder.  Then  the  enucleating  finger 
will  pass  across  to  the  other  lobe,  beneath  the  posterior  commissure 
of  the  prostate.  Finally,  when  enucleation  of  the  second  lobe  has 
been  completed,  the  prostate  is  found  fully  detached  from  surrounding 
structures,  except  where  the  urethra  annexes  it  to  the  triangular 
ligament.  At  this  stage  it  is  said  the  prostatic  urethra  may  slip  out 
of  the  prostate,  remaining  attached  to  the  triangular  ligament;  but 


Fig.  1053.— Enlarged  prostate  removed  by  suprapubic  prostatectomy.  Catheter  in 
urethra  pointing  toward  bladder.    Prostate  on  its  inferior  surface.     Episcopal  Hospital. 

what  usually  occurs  is  that  it  tears  off  just  on  the  vesical  side  of  the 
verumontanum,  and  is  removed  with  the  prostate.  The  anterior 
commissure  of  the  gland  may  give  away  during  these  manipulations, 
but  in  many  cases  the  prostate  is  removed  in  one  "mass  (Fig.  1053). 
It  is  then  withdrawn  from  the  bladder,  and  the  cavity  from  which 
it  has  been  enucleated  rapidly  contracts.  Bleeding  rarely  is  alarming, 
and  usually  is  rapidly  controlled  by  hot  douching.1  The  bladder  is 
then  closed  around  a  large  drainage  tube,  as  in  cases  of  suprapubic 
cystotomy.  The  tube  should  be  retained  for  a  week  or  more,  but 
the  patient  may  leave  his  bed  as  soon  as  proves  agreeable  to 
him.  The  bladder  is  irrigated  once  daily  through  the  suprapubic 
wound  as  long  as  this  remains  open.  Should  it  show  no  tendency  to 
close  by  the  third  week,  a  catheter  should  be  passed  once  daily  by  the 
urethra.  Removal  of  the  prostatic  urethra  will  have  shortened  the 
urethral  channel  considerably,  the  vesical  orifice  now  being  close  to 
the  triangular  ligament.     Stricture  formation  is  unusual.     The  chief 

1  In  cases  of  persistent  bleeding,  the  bed  of  the  prostate  may  be  packed  with 
gauze,  held  in  place  by  a  few  sutures  of  catgut  passed  through  the  free  edges  of 
mucous  membrane  forming  the  roof  of  the  cavity.  One  end  of  the  gauze  projects 
from  the  suprapubic  wound,  and  the  packing  can  thus  be  removed  as  soon  as  the 
catgut  sutures  are  absorbed  (Deaver  and  Ashhurst). 


109G  SURGERY  OF  THE  URETHRA  AND  PROSTATE 

dangers  are  shock  and  hemorrhage.  The  immediate  mortality  varies 
from  5  to  7  per  cent,  in  skilled  hands,  and  the  results  are  exceedingly 
good.  Voluntary  urination  is  restored;  no  residual  urine  remains; 
and  the  patient's  life  is  lengthened  by  many  years. 

Perineal  Prostatectomy  I  think  is  best  reserved  for  small  fibrous 
prostates.  The  best  exposure  is  gained  by  the  technique  of  the  French 
school,  elaborated  by  Proust  (1903).  The  patient  lies  on  his  back  with 
his  buttocks  raised  on  a  sand  pillow,  and  thighs  flexed  on  the  abdomen 
as  far  as  possible,  thus  inverting  the  pelvis  and  bringing  the  perineum 
nearly  horizontal.  A  staff  is  fixed  in  the  urethra,  and  through  a  trans- 
verse incision,  with  convexity  forward,  extending  from  one  ischiatic 
tuberosity  to  the  other,  the  perineal  center  is  exposed.  Then  the 
attachment  of  the  external  sphincter  ani  to  this  is  divided,  and  the 
dissection  continued  posterior  to  the  transverse  perineal  muscles. 
By  drawing  the  anus  toward  the  coccyx,  the  recto-urethralis  muscle 
is  put  on  the  stretch;  and  by  dividing  this  close  to  the  membranous 
urethra  (which  is  not  opened),  the  surgeon  opens  the  space  between 
the  two  layers  of  the  aponeurosis  of  Denonvilliers  (Fig.  1050),  known 
as  the  "  espace  decollable  retroprostatique."  The  rectum  now  falls 
away  from  the  anterior  structures  and  appears  like  a  loop  of  intestine 
floating  free  in  the  peritoneal  cavity;  it  is  covered  by  the  posterior 
layer  of  this  aponeurosis,  while  the  anterior  layer  still  covers  the  pros- 
tate and  seminal  vesicles.  It  is  to  be  recalled  that  the  aponeurosis 
of  Denonvilliers  really  is  an  obliterated  sac  of  peritoneum,  analogous 
to  the  processus  vaginalis  of  the  testicle. 

Beyond  the  anterior  layer  of  the  aponeurosis  of  Denonvilliers  the 
prostate  can  now  be  indistinctly  felt,  floating  away  as  soon  as  touched. 
The  urethra  therefore  is  opened,  at  the  apex  of  the  prostate;  a  pros- 
tatic tractor  is  inserted  into  the  bladder,  and  its  blades  are  turned  so  as 
to  catch  on  the  vesical  surface  of  the  prostate.  The  prostate  being  thus 
steadied,  its  sheath  (anterior  layer  of  the  aponeurosis  of  Denonvilliers) 
is  opened  over  one  of  the  lateral  lobe's  of  the  prostate,  by  an  incision 
parallel  to  the  urethra.  By  the  finger  or  a  blunt  dissector,  this  sheath 
is  then  stripped  from  each  lateral  lobe,  with  utmost  thoroughness. 
Proust  says  that  time  apparently  lost  at  this  stage  of  the  operation 
will  be  found  to  accelerate  matters  considerably  at  a  later  stage. 
When  the  prostate  is  thus  freed  of  all  its  attachments  except  to  the 
urethra  and  ejaculatory  ducts,  the  prostatic  tractor  is  removed,  and 
the  floor  of  the  urethra  is  split  open  from  the  apex  of  the  prostate 
back  to  but  not  into  the  neck  of  the  bladder.  This  cut  hemisects  the 
prostate  as  well,  and  each  lateral  lobe  in  turn  is  dissected  off  the  lateral 
and  upper  aspects  of  the  urethra,  by  scissors.  If  possible,  each  lateral 
lobe  is  removed  entire,  not  by  morcellement.  Proust  ligates  the  ejac- 
ulatory ducts,  thinking  this  lessens  the  chances  of  orchitis.  The  bladder 
is  drained  by  rubber  tube,  and  the  floor  of  the  prostatic  urethra  is 
sutured  over  this  as  a  guide,  as  far  forward  as  the  triangular  ligament, 
where  the  tube  emerges.  The  perineal  wound  is  drained  by  gauze 
wicks,  and  is  partly  closed  by  buried  sutures. 


PERINEAL  PROSTATECTOMY  1097 

Young  introduced  in  1903,  and  has  practised  in  a  large  series  of  cases 
with  surprising  success  and  wonderfully  low  mortality,  an  operation 
which  he  calls  "conservative"  perineal  prostatectomy.  The  technique 
is  much  the  same  as  that  of  the  French  school,  except  that  an  attempt 
is  made  to  preserve  the  ejaculatory  ducts  by  leaving  intact  the  pos- 
terior commissure  of  the  gland,  in  which  they  run.  It  seems  very 
doubtful  whether  this  feature  of  the  operation  is  of  any  value. 

Atrophy  of  the  Prostate  and  Contracture  of  the  Neck  of  the  Bladder 
(Chetwood,  1901). — Usually  these  occur  together,  and  are  the  result 
of  long  continued  inflammatory  changes.  The  sclerotic  type  of  pros- 
tatic enlargement,  already  described,  can  with  difficulty  be  separated 
from  atrophy  of  the  gland.  The  symptoms  are  similar  to  those  seen 
in  enlargement  of  the  prostate,  since  the  sclerosis  of  the  tissues  inter- 
feres with  urination.  Especially  frequent,  according  to  Young,  are 
chronic  inflammatory  changes  in  the  prostatic  utricle.  Another  fre- 
quent factor  in  urinary  obstruction  in  these  cases  is  a  "  bar  at  the  neck 
of  the  bladder"  (Guthrie,  1834)  usually  in  the  form  of  a  dense  fibrous 
ring  around  the  vesical  orifice  of  the  urethra.  Chronic  prostatitis 
usually  coexists.  The  diagnosis  is  made  by  recognizing  the  small 
sclerotic  prostate  on  rectal  examination,  and  by  use  of  the  cystoscope 
which  usually  shows  an  abnormal  condition  of  the  prostatic  urethra 
and  vesical  neck. 

Treatment. — Treatment,  even  by  specialists  in  genito-urinary  sur- 
gery, is  not  always  satisfactory.  The  condition  of  the  urine  should 
be  attended  to;  and  methods  already  advised  in  cases  of  chronic 
prostatitis  may  be  tried.  Best  results  follow  direct  treatment  of  the 
prostatic  urethra  through  the  cystoscope.  If  a  bar  at  the  neck  of  the 
bladder  is  found,  it  may  be  punched  out  by  one  of  the  modern  instru- 
ments copied  after  Mercier's  original  prostatotome  and  prostatectome 
(1837),  or  relief  may  be  secured  by  the  Bottini  galvano-cautery  opera- 
tion. Prostatectomy  (by  the  perineal  route)  may  be  considered  the  last 
resort. 

Carcinoma  of  the  Prostate  is  now  recognized  as  much  more  frequent 
than  formerly  supposed.  It  probably  occurs  in  not  less  than  10  per 
cent,  of  patients  who  complain  of  symptoms  of  urinary  obstruction 
from  prostatic  disease.  The  malignant  growth  appears  to  originate 
usually  in  that  portion  of  the  prostate  posterior  to  the  urethra  and 
below  the  ejaculatory  ducts.  It  tends  to  infiltrate  upwards  invading 
the  vasa  deferentia  and  seminal  vesicles  long  before  it  spreads  into 
the  prostatic  tissues  immediately  adjacent  to  the  neck  of  the  bladder. 
Patients  seldom  come  under  observation  while  the  growth  is  still 
operable.  In  some  cases  the  earliest  indication  of  trouble  is  not  the 
occurrence  of  local  symptoms,  but  the  discovery  of  metastasis  in  the 
bones  of  the  pelvis,  trunk,  or  limbs.  Usually  it  is  found  that  a  hard, 
nodular,  fixed  tumor  occupies  the  region  of  the  prostate,  and  that  the 
rectal  mucous  membrane  does  not  glide  easily  over  the  enlarged  organ 
as  is  the  case  in  benign  enlargement.  Referred  pains  are  frequent  in 
advanced  cases. 


109S  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

Treatment. — Treatment  usually  must  be  palliative.  A  radical  oper- 
ation, involving  removal  of  the  prostate  and  seminal  vesicles,  resection 
of  the  neck  of  the  bladder,  and  suture  of  the  membranous  urethra  to 
the  remaining  vesical  wall,  has  been  devised  and  practised  by  Young, 
with  fair  success.  Where  such  a  radical  operation  is  impracticable,  he 
has  practised  a  partial  perineal  prostatectomy  with  preservation  of  the 
urethra  and  vesical  mucosa;  he  thinks  that  in  about  GO  per  cent,  of 
cases  excellent  functional  results  may  be  expected  which  will  be 
maintained  so  long  as  the  patient  lives. 

Sarcoma  of  the  Prostate  is  rare.  A  tumor  in  a  child  or  young  person 
probably  is  sarcomatous;  it  grows  very  rapidly,  and  almost  always  is 
inoperable.  The  earliest  symptom  often  is  complete  retention  of 
urine;  less  often  do  symptoms  of  incomplete  urinary  obstruction 
occur,  or  rectal  symptoms.  Death  occurs  within  three  months  to 
two  years. 


CHAPTER   XXVIII. 
SURGERY  OF  THE  MALE  GENITAL  ORGANS. 

SURGERY    OF    THE   PENIS. 

Congenital  Deformities. — Hypospadias. — The  most  frequent  of  these 
is  hypospadias,  in  which  there  is  a  defect  in  the  floor  of  the  urethra, 
extending  from  the  meatus  a  variable  distance  backward.  It  occurs 
once  in  about  300  males,  and  is  due  to  failure  of  coalescence 
between  the  two  lateral  portions  of  the  penis  on  its  under  surface. 
In  glandular  hypospadias  the  urinary  meatus  is  displaced  only  slightly, 
and  unless  it  is  as  low  as  the  region  of  the  frenum  no  treatment  usually 
is  required.  In  penile  hypospadias  (Fig.  1054)  the  opening  usually  occurs 
at  the  junction  of  the  penis  and  scrotum  (peno-scrotal  hypospadias) 


Fig.  1054. — Penile  hypospadias.     Episcopal  Hospital. 


but  may  be  anterior  to  this  site.  In  the  most  marked  deformity  the 
opening  is  in  the  perineum,  there  is  usually  cleft  scrotum,  the  penis  is 
rudimentary,  and  there  is  resemblance  to  the  condition  known  as 
hermaphrodism  (Fig.  1055).  In  all  cases  of  hypospadias  there  is  down- 
ward incurvation  of  the  penis,  and  the  prepuce  usually  is  abnormal  in 
form  or  attachment. 

Treatment. — Treatment  involves  some  form  of  plastic  operation, 
and  the  best  time  for  this  is  about  the  age  of  six  years.  It  is  very 
important  to  employ  only  such  skin  in  plastic  operations  as  will  remain 
free  from  hair  throughout  life.    In  most  cases  the  bladder  should  be 

(1099) 


1100 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


drained  through  the  perineum  during  the  first  week  after  operation, 
or  until  the  sutured  structures  have  firmly  united.     In  glandular 


Fig.  1055. — Perineal  hypospadias  and  cleft  scrotum  in  a  boy  aged  five  years.     The  right 
testicle  is  undescended.     Episcopal  Hospital. 


Fig.  1056.— Beck's  operation  for  hypospad- 
ias.    (Watson  and  Cunningham.) 


Fig.  1057. — Beck's  operation.     (Watson 
and  Cunningham.) 


hypospadias  Beck's  operation  (1907)  is  the  best  (Figs.  1056  and  1057) : 
the  urethral  orifice  and  2  or  3  cm.  of  the  urethra  are  dissected  free,  and 


CONGENITAL  DEFORMITIES  OF   THE  PENIS 


1101 


the  glans  is  perforated  from  base  to  summit  by  a  bistoury,  this  tract 
is  dilated,  and  the  previously  mobilized  urethra  is  drawn  through  and 
the  meatus  sutured  in  its  normal  posi- 
tion. A  similar  operation  may  succeed 
when  the  urethral  opening  is  in  the  penis 
not  too  far  from  the  glans;  but  in  most 
cases  of  penile  and  in  all  cases  of  peno- 
scrotal and  perineal  hypospadias,  it  is 
necessary  to  construct  a  new  urethra  by 
skin  flaps.  A  good  method  in  cases  of 
peno-scrotal  hypospadias  is  to  outline 
two  corresponding  rectangular  flaps  from 
the  under  surface  of  the  penis  and  the 
anterior  median  raphe  of  the  scrotum,  re- 
spectively, as  indicated  in  Fig.  1058.  The 
denuded  edges  are  sutured  together, 
and  after  several  weeks,  when  union  is 
firm,  the  penis  with  the  adherent  scrotal 
raphe  (which  forms  the  floor  of  the  new 
urethra)  are  cut  free  from  the  scrotum,  and 

.,  ,.  i  •      i         i-  t  tiG.  10o8. — Bucknall  s  operation 

the  raw  surfaces  are  covered  in  by  sliding  forpeno-scrotaihypospadias(i907). 
flaps  together  from  the  sides,  or  by  bring- 
ing the  redundant  prepuce  over  the  under  surface  of  the  penis  as  a 
bridge.  After  a  penile  urethra  has  been  constructed  in  this  way,  it 
may  be  transplanted  into  the  glans,  according  to  Beck's  operation, 
on  a  subsequent  occasion.  Cantas  (1911)  used  a  plastic  flap,  with 
pedicle,  from  the  thigh,  containing  a  section  of  the  long  saphenous 
vein,  which  served  as  the  new  urethra. 


Fig.  1059. — Epispadias;  age  six  years.     Episcopal  Hospital. 


Epispadias. — In  epispadias  the  roof  of  the  urethra  is  deficient  for 
a  greater  or  less  distance  back  from  the  normal  site  of  the  meatus 
(Fig.  1059).     It  is  treated  by  operations  analogous  to  those  employed 


L102 


si  ruery   OF   THE   MALE  GENITAL   ORGANS 


for   hypospadias.     Cantwell's   operation    (1895)    is    commended   by 
Binnie  (Fig.  L060). 


Fig.  1060. — Cantwell's  operation  for  epispadias:  a  new  urethra  is  formed  by  inverting 
skin-flaps;  the  corpora  cavernosa  are  then  separated  in  the  mid-line;  the  new  formed 
urethra  is  placed  in  the  floor  of  the  channel  thus  made;  and  finally  the  cavernous  bodies 
are  sutured  together  over  the  new  urethra. 

Hermaphrodism.—  This  is  a  condition  in  which  an  individual  pos- 
sesses the  generative  organs  of  both  sexes.  It  is  excessively  rare;  in 
the  vast  majority  of  cases  only  false  hermaphrodism  exists:  a  male 
with  a  perineal  hypospadias,  cleft  scrotum,  rudimentary  penis,  and 
undescended  testicles  may  resemble  a  female  on  casual  inspection 
(Fig.  1055);  or  a  female  with  abnormally  large  clitoris  a  d  congenital 
absence  of  the  vag'na  may  lesemble  a  male  hypospadiate.  Treatment 
involves  operative  cure  of  the  predominant  deformity    when  this  is 


Phimosis. — Phimosis  is  the  condition  in  which  the  prepuce  cannot 
be  retracted  over  the  glans.  It'  is  rare  as  a  congenital  deformity,  most 
cases  so  classed  being  merely  instances  of  adherent  prepuce  the  result 
of  balano-posthitis :  in  these  retraction  is  possible,  though  difficult. 
Cure  follows  daily  retraction,  cleansing,  and  application  of  zinc  oxide 
ointment  to  the  inflamed  parts.  Most  cases  of  true  phimosis  (Fig.  1061) 
are  the  result  of  neglect  of  the  parts  in  infancy  and  early  childhood, 

the  preputial  orifice  re- 
maining infantile  in  size 
while  the  penis  has  con- 
tinued to  grow.  Mere 
elongation  or  redundancy 
of  the  prepuce  usually  is 
congenital  (Fig.  1062).  In 
many  cases  phimosis  de- 
velops as  a  temporary 
condition  in  adult  life, 
as  a  complication  of  bal- 
ano-posthitis from  chan- 
croids or  gonorrhea. 

Treatment. — Treatment 
may  be  by   incision,  ex- 
cision,    or     circumcision. 
Incision  (dorsal  slit  of  the 
prepuce)  was  mentioned  at  p.  1063;  it  is  used  mostly  in  cases  com- 
plicating balano-posthitis.     Excision  of  a  wedge  shaped  portion  of  the 


Fig.  1061. — Phimosis.     Age  sixteen  years. 
Episcopal  Hospital. 


CIRCUMCISION 


1103 


prepuce  is  seldom  or  never  employed.  Circumcision  is  the  typical 
operation.  Various  special  forceps  have  been  devised  to  simplify  the 
operation  but  their  place  is  readily  supplied  by  clamping  the  foreskin 
between  the  handles  of  a  pair  of  scissors,  the  redundant  foreskin  being 
cut  off  with  another  pair  (Fig.  1063).  The  section  should  be  made 
obliquely,  removing  more 
tissue  from  the  dorsum  of 
the  penis  than  from  the 
region  of  the  frenum.  The 
clamp  should  be  applied 
at  a  level  which  corre- 
sponds with  the  sulcus  be- 
hind the  corona  glandis, 
and  the  skin  should  be 
drawn  well  in  front  of  the 
glans  before  the  clamp  is 
tightened.  When  the  re- 
dundant tissue  is  cut  away 
and  the  clamp  is  removed 

it  will  be  found  that  the  skin  surface  of  the  prepuce  retracts,  while 
its  mucous  layer  still  covers  the  glans.  The  mucous  layer  is  then 
slit  up  the  dorsum,  with  scissors,  as  far  as  the  corona  glandis.  It  is 
not  necessary  to  trim  off  the  triangular  flaps  of  mucosa  thus  formed, 
as  by  careful  suturing  no  redundant  tissue  is  left.  Next  every  bleeding 
point  should  be  caught  in  hemostats  and  ligated  with  fine  catgut.    Neglect 


Fig.  1062. — Redundant  prepuce. 
Hospital. 


Children's 


Fk 


-Circumcision  with  two  pai 


pal  Hospital. 


of  this  precaution  usually  results  in  formation  of  a  hematoma  and 
breaking  down  of  the  wound.  Finally  the  skin  and  mucous  layer  of 
the  prepuce  are  sutured  together  with  interrupted  sutures  of  chromic 
catgut.  The  first  suture  is  introduced  at  the  frenum,  the  second  in 
the  mid-line  on  the  dorsum  of  the  penis,  the  third  and  fourth  at  the 
midpoints  on  the  right  and  left  sides,  and  such   other   intervening 


1101 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


sutures  as  are  required  to  secure  neat  apposition.  The  ends  of  all 
these  sutures  are  left  long  after  tying,  and  the  dressing  (a  thin  roll  of 
gauze)  is  held  in  place  by  knotting  the  free  ends  of  the  sutures  over  it 
(Fig.  1064).  This  roll  of  gauze  should  be  applied  a  little  slack,  so  as  not 
to  produce  strangulation  should  erections  occur.     No  other  dressing  is 


Fig.' 1064. — Dressing  for  circumcision.     Episcopal  Hospital. 


used.  In  the  course  of  ten  days  or  two  weeks  this  gauze  may  be 
peeled  off,  as  the  chromic  catgut  sutures  will  have  been  absorbed.  In 
the  meantime  the  seat  of  operation  requires  no  treatment. 

Paraphimosis. — Paraphimosis  is  the  condition  in  which  the  foreskin 
has  been  retracted  over  the  glans  and  cannot  be  replaced  owing  to 

swelling  of  the  glans  or  edema 
of  the  foreskin  (Fig.  1065). 
The  tightest  band  of  constric- 
tion, back  of  the  corona,  may 
become  ulcerated  from  pres- 
sure ;  this  always  occurs  before 
there  is  danger  of  strangula- 
tion of  the  penis. 

Treatment. — In  recent  cases 
it  is  usually  possible  to  reduce 
the  paraphimosis  by  pushing 
the  glans  upward  with  the 
thumbs,  while  the  index  and 
middle  fingers  of  both  hands, 
applied  behind  the  corona, 
pull  the  foreskin  forward.  If 
reduction  is  not  accomplished 
in  this  way,  it  is  often  advised 
that  the  constricting  band  be  divided ;  but  as  a  matter  of  fact  usually 
no  treatment  is  required  beyond  bathing  the  parts  in  hot  water  and 
keeping  the  penis  elevated  to  favor  reduction  of  the  edema.    In  the 


Fig.  1065. — Paraphimosis  from  gonorrhea;  nine 
days'  duration.     Episcopal  Hospital. 


CARCINOMA  OF   THE  PENIS  1105 

course  of  a  few  days  the  foreskin  can  be  drawn  down  again  in  most 
cases,  but  sometimes  permanent  thickening  from  lymphedema  persists 
and  may  require  excision  or  circumcision. 

Balanitis  and  Balano-posthitis. — Balanitis  is  inflammation  of  the 
glans  penis;  posthitis  is  inflammation  of  the  prepuce.  Usually  both 
glans  and  prepuce  are  inflamed  (balano-posthitis).  In  children  this 
condition  is  a  frequent  complication  of  adherent  prepuce;  in  adults 
it  occurs  as  a  complication  of  gonorrhea  or  chancroids,  being  predis- 
posed to  by  phimosis  or  elongation  of  the  prepuce1.  In  the  aged, 
formation  of  a  preputial  calculus  is  an  occasional  complication. 

Treatment. — In  cases  with  phimosis  or  adherent  prepuce,  dorsal 
incision  of  the  prepuce,  or  circumcision  should  be  done,  the  former 
being  preferable  in  gonorrheal  or  chancroidal  cases.  Inflammation 
may  be  reduced  before  and  after  operation  by  instillations  of  weak 
silver  nitrate  solution  between  glans  and  prepuce. 

Herpes  Progenitalis. — Herpetic  vesicles  sometimes  develop  on  the 
penis,  especially  on  the  mucous  layer  of  the  prepuce;  they  may  occur 
seemingly  spontaneously,  or  soon  after  coitus.  The  vesicles  resemble 
those  seen  in  cases  of  herpes  occurring  elsewhere  on  the  body.  The 
affection  appears  first  as  one  or  several  minute  reddish  papules  which 
turn  into  vesicles  in  the  course  of  a  few  hours.  Often  they  .assume  a 
crescentic  outline.  There  is  some  itching  and  tingling,  and  after  the 
vesicles  rupture  contact  with  the  urine  causes  burning  pain.  Patients 
usually  are  subject  to  recurring  attacks. 

Treatment. — The  general  health  should  be  given  attention,  and  any 
local  source  of  irritation  (phimosis,  etc.)  should  be  appropriately 
treated.  If  the  herpetic  vesicles  are  kept  clean  and  dry,  they  usually 
heal  within  a  few  days.  Astringent  washes  (1  per  cent,  sulphate  of 
zinc,  or  acetate  of  lead)  should  be  applied  once  daily,  the  parts  being 
then  thoroughly  dried,  and  powdered. 

Venereal  Warts  (Verrucae  Acuminatse). — This  affection  was  men- 
tioned at  p.  290.  It  has  no  necessary  connection  with  venereal  dis- 
ease. The  warts  usually  occur  in  persons  with  phimosis  or  redundant 
prepuce,  and  are  the  result  of  uncleanliness  (Fig.  1066). 

Treatment. — In  mild  cases  it  is  sufficient  to  apply  caustics  (fuming 
nitric  acid)  every  day  or  so  until  the  warts  shrivel  up  and  drop  off; 
but  in  cases  complicated  by  phimosis  this  should  be  relieved  by 
appropriate  means,  and  the  warts  should  be  excised  and  their  bases 
cauterized. 

Carcinoma. — Carcinoma  is  the  only  tumor  of  frequent  occurrence 
on  the  penis.  It  may  develop  in  an  old  venereal  scar;  is  predisposed 
to  by  the  existence  of  phimosis  or  balano-posthitis;2  but  often  no 
cause  is  evident.     It  presents  the  same  characteristics  as  carcinoma 

1  Under  the  name  of  "the  fourth  venereal  disease"  Corbus  and  Harris  (1909) 
described  a  form  of  erosive  balanitis  due  to  symbiosis  of  a  spirochete  and  a 
vibrio.  The  spirochete  is  identical  with  that  of  Vincent's  angina,  found  in  the 
mouth,  and  the  infection  is  believed  to  be  conveyed  to  the  prepuce  and  glans  by 
unnatural  sexual  practices. 

2  Leukoplakia  of  the  glans  is  recognized  a  a  pre-cancerous  condition. 

70 


IKK) 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


in  other  regions  of  the  body.  Usually  it  arises  on  the  glans  or  the 
prepuce.  The  squamous-celled  type  is  not  highly  malignant.  A  papil- 
lary form  is  more  usual,  is  much  more  malignant,  and  presents  irreg- 
ular projections,  resembling  venereal  warts  except  for  the  hardness 
of  their  bases  and  margins,  and  the  presence  of  ulceration,  which 
occurs  early.  The  inguinal  lymph  nodes  on  both  sides  are  involved 
early  in  the  papillary  variety,  not  until  later  in  the  squamous-celled 
type  of  carcinoma.     Invasion  of  the  pelvic  nodes  also  occurs. 


Fig.  1066. — Venereal  warts  from  phimosis.     Duration  seven  months.     No  venerea 
disease.     Episcopal  Hospital. 


Treatment. — If  the  carcinoma  has  not  spread  beyond  the  glans, 
amputation  of  the  penis  is  sufficient;  but  if  the  corpora  cavernosa  have 
become  infiltrated  extirpation  of  the  entire  penis  is  necessary.  In  all 
cases  the  inguinal  lymph  nodes  should  be  excised;  usually  this  may 
be  done  at  the  same  time  as  the  operation  on  the  penis,  and  then  always 
as  the  first  step  of  the  operation;  but  if  the  tumor  is  very  septic,  it  is 
best  to  postpone  removal  of  the  inguinal  lymph  nodes  until  the  lower 
wound  has  healed. 

Amputation  of  the  Penis  involves  removal  only  of  the  phallic  portion 
of  the  penis:  a  rubber  tube  is  tied  around  the  base  of  the  organ,  to 
control  bleeding;  a  circular  incision  is  made  through  the  skin  well 
behind  the  seat  of  disease,  and  the  skin  is  allowed  to  retract.  The  cor- 
pora cavernosa  are  then  divided  at  the  base  of  the  skin-flap  and  closed 
transversely  by  sutures.  The  urethra  (with  the  corpus  spongiosum) 
is  dissected  free  for  a  centimeter  or  more  in  front  of  this  point,  and  is 
divided.  "The  urethra  is  then  slit  up  in  three  places,  one  below  and 
two  above;  the  three  square  flaps  so  formed  are  then  turned  back  and 
their  corners  cut  off.  This  makes  three  small  triangular  flaps  which 
when  spread  out  form  one  large  triangle.  The  skin  is  then  sutured 
accuratelv  to  the  edges  of  this  triangle,  and  no  raw  surface  is  left" 
(Q.  G.  Davis,  1897). 

Extirpation  of  the  Penis  (Ni  hols,  1909). — The  scrotum  is  slit  open 
from  the  penoscrotal  juncture  to  the  perineum,  and  the  bulbous 
urethra  is  isolated  and  divided,  and  its  vesical  end  fixed  to  the  skin 
of  the  perineum,  being  split  on  its  under  surface  for  2  cm.  The  incision 
is  next  carried  around  the  base  of  the  penis,  the  suspensory  ligament  is 


CONGENITAL  ANOMALIES 


1107 


divided,  the  crura  cut,  and  the  entire  penis  is  removed.  A  catheter 
is  left  in  the  bladder.  In  advanced  cases  it  is  necessary  to  remove  both 
testicles  and  spermatic  cords  as  far  as  the  internal  abdominal  ring, 
so  as  to  permit  complete  extirpation  of  the  inguinal  lymphatics. 

SURGERY    OF    THE    TESTICLES,   SCROTUM,    AND    SPERMATIC 

CORD. 

Congenital  Anomalies. — In  some  rare  cases  one  or  both  testicles 
may  be  absent.  A  much  more  usual  anomaly  is  non-descent  of  the 
testicle,  on  one  or  both  sides,  called  respectively  monor  chid  ism  and 
cryptorchidism.  The  affection  is  more  frequent  on  the  right.  The 
testicle  may  be  retained  in  the  abdominal  cavity  or  may  be  lodged 
in  the  inguinal  canal  or  at  the  external  ring.  Inguinal  hernia  usually 
is  present  as  a  complication.  Rarely  the  testicle  is  misplaced,  being 
found  in  the  perineum  or  on  the  thigh.  In  most  cases  the  diagnosis 
of  non-descent  or  misplacement  is  readily  made  by  observing  the 
absence  of  the  testicle  from  the  scrotum,  and  its  presence  in  the  ingui- 
nal canal  or  elsewhere.  Sometimes  the  testicle  is  wandering,  slipping 
up  into  the  inguinal  canal  when  the  cremaster  contracts,  and  at  other 
times  remaining  in  the  scrotum  (Figs.  1067  and  106S). 


Fig.  1067. — Wandering  testicle:  testi- 
cle now  in  inguinal  canal.  Age  fifteen 
years.     Episcopal  Hospital. 


Fig.  1068. — Wandering  testicle:  testi- 
cle now  in  upper  part  of  scrotum.  Epis- 
copal Hospital. 


Treatment. — A  testicle  which  remains  in  the  inguinal  canal  or  at 
the  external  ring  is  constantly  exposed  to  injury;  one  which  comes  and 
goes  dilates  the  inguinal  canal  and  predisposes  to  the  development 
of  hernia,  and  is  itself  liable  to  torsion  (see  below).  The  condition 
should  be  remedied  by  operation,  and  the  best  age  for  this  is  about  six 
years.  The  undescended  testicles,  according  to  Corner  (1907),  possess 
the  power  of  producing  spermatozoa  only  for  a  short  time,  usually 
from  the  age  of  twenty  to  twenty-two  years,  though  their  function 
of  internal  secretion  may  be  sufficient  to  ensure  the  acquirement 
of  secondary  sexual  characteristics  at  the  usual  age  of  puberty.  In 
any  case,  their  removal  is  contraindicated  unless  they  are  actually 
diseased.     The  main  therapeutic  indication  is  to  place  the  testicle 


1108  SURGERY  OF  THE  MALE  GENITAL  ORGANS 

in  :i  situation  where  it  sliall  not  be  exposed  to  injury.  If  possible  it 
should  be  brought  down  into  the  scrotum;  but  if  this  cannot  be  done, 
it  should  be  replaced  within  the  abdominal  cavity.1  The  operation 
is  begun  by  opening  the  inguinal  canal,  as  in  the  hernia  operation. 
The  testicle  is  exposed,  and  a  hernial  sac  if  present  is  excised  and  the 
opening  in  the  parietal  peritoneum  is  closed.  If  the  cord  is  not  long 
enough  to  enable  the  testicle  to  be  replaced  in  the  scrotum,  it  often 
is  possible  to  lengthen  it  (Be van,  1903)  by  careful  division  of  fibrous 
bands  and  freeing  the  structures  well  around  the  internal  ring,  by 
ligation  and  division  of  the  cremasteric  artery,  or  even  by  excision 
of  all  the  constituents  of  the  cord  except  the  vas  and  its  accompany- 
ing vessels;  the  latter  step  seldom  is  necessary,  but  according  to  Bevan 
sacrificing  the  spermatic  vessels  will  not  lead  to  gangrene  of  the  tes- 
ticle. By  division  of  the  deep  epigastric  vessels  the  course  of  the 
vas  may  be  shortened  (Davison,  1911).  When  the  organ  has  been 
brought  down  into  the  scrotum,  the  external  ring  should  be  sutured 
around  the  cord  preventing  reascent  of  the  testicle.  The  cord  should 
not  be  transplanted  as  in  the  Bassini  hernia  operation,  but  should  be 
treated  as  in  Ferguson's  method  (p.  843). 

Torsion  of  the  Testicle,  generally  traumatic  in  origin  (straining 
efforts,  contortions  of  the  body,  etc.),  occurs  usually  in  children  with 
unduly  movable  testicles.  In  most  cases  the  tunica  vaginalis  extends 
up  to  the  internal  ring,  and  congenital  hydrocele  (p.  1115)  may  be 
present.  The  symptoms  are  acute,  sickening  pain  in  the  inguinal  canal 
or  scrotum  according  to  the  site  of  the  testicle;  the  testicle  becomes 
a  little  swollen,  and  is  extremely  tender.  The  diagnosis  must  be  made 
from  strangulated  inguinal  hernia  and  from  inflamed  hydrocele  of 
the  cord.  In  these  conditions  a  normally  placed  and  symptomless 
testicle  usually  is  present.  Treatment  is  by  operation,  which  consists 
in  uncoiling  the  twist  and  fixing  the  testicle  in  normal  position  by 
means  of  sutures;  or  in  castration  if  gangrene  of  the  testicle  has 
occurred. 

Inflammation  of  the  Testicle. — Orchitis  implies  inflammation  of 
the  testis  proper;  wThile  inflammation  of  the  epididymis  is  called 
epididymitis.  In  most  cases  both  component  parts  of  the  testicle  are 
affected  (epididymo-orchitis) ,  but  almost  invariably  one  or  the  other 
affection  dominates  the  clinical  picture.  Apart  from  trauma,  which 
is  not  a  very  frequent  cause,  the  disease  is  oftenest  due  to  infection 
carried  by  the  blood-stream  (orchitis)  or  extending  from  the  urethra 
through  the  vas  deferens  (epididymitis).  Orchitis  is  much  more  fre- 
quent in  boys  than  in  adults,  and  occurs  as  a  complication  of  mumps 
(Fig.  1069),  tonsillitis,  influenza,   etc.     The  attack  lasts  about  four 

1  The  supposition  that  a  mal-placed  testicle  is  more  prone  to  the  development 
of  malignant  tumors  than  the  normally  situated  organ,  is  cited  by  some  as  justifica- 
tion for  orchidectomy  (castration)  in  these  cases.  But  if  true,  it  would  not  be 
the  mal-position  which  created  the  predisposition  to  malignant  disease,  but  some 
developmental  defect  in  the  organ  itself  and  the  occurrence  of  malignant  changes 
would  be  no  more  frequent  if  the  testicle  were  retained  in  the  abdomen  than  if  it 
were  replaced  in  the  scrotum. 


ORCHITIS  AND  EPIDIDYMITIS 


1109 


days.  Usually  the  right  testis  is  affected,  but  occasionally  both  sides 
are  attacked  one  after  the  other.  Some  atrophy  may  occur  subse- 
quently. Suppuration  often  occurs  in  cases  complicating  typhoid 
fever.  Epididymitis  usually  is  a  complication  or  sequel  of  gonorrhea, 
occurring  from  the  third  to  the  sixth  week  of  the  disease.  Some- 
times it  occurs  after  the  passing  of  a  sound  or  catheter,  especially  in 
cases  of  prostatic  enlargement.  The  left  side  is  affected  oftener  than 
the  right,  but  both  sides  may  be  involved  in  turn. 

Symptoms. — Symptoms  of  orchitis  and  epididymitis  are  of  rather 
sudden  onset,  but  prodromes  (malaise,  headache,  nausea,  creepiness, 
and  chilliness)  may  occur.  The  earliest  symptoms  may  be  referred 
to  the  abdomen,  and  may  be  mistaken  for  those  of  appendicitis. 
The  testicle  becomes  acutely  painful,  excessively  tender,  and  swollen; 
most  of  the  swelling  is  due 
to  inflammatory  effusion 
into  the  tunica  vaginalis 
(acute  hydrocele).  The  scro- 
tum may  become  red  and 
edematous.  The  tempera- 
ture sometimes  is  high,  and 
the  patient  may  appear  very 
ill,  at  least  for  a  time.  If 
the  patient  keeps  on  his  feet, 
and  particularly  if  the  tes- 
ticle is  allowed  to  hang  un- 
supported, all  the  symptoms 
are  aggravated,  and  there 
may  be  dragging  abdominal 
pains.  The  diagnosis  between 
orchitis  and  epididymitis 
may  be  made  by  noting  the 
history  of  the  case  and  the 
probable  cause  of  the  scrotal 
swelling;  by  observing  that 
in  epididymitis  the  swelling  begins  in  the  globus  minor,  spreads  to 
the  globus  major,  and  that  when  the  entire  epididymis  is  affected  it 
forms  a  "boat-shaped"  enlargement  on  the  outer  and  back  part  of 
the  testis.  Most  of  the  scrotal  enlargement,  as  already  remarked,  is 
caused  by  acute  hydrocele  of  the  tunica  vaginalis.  In  orchitis  the 
smooth  globular  form  of  the  testicle  is  felt,  and  the  epididymis  is  not 
palpably  enlarged. 

Treatment. — The  patient  should  be  put  to  bed,  and  the  scrotum 
elevated.  Heat,  especially  in  the  form  of  a  flaxseed  poultice,  is  better 
than  cold  as  a  local  application.  If  injections  have  been  in  use,  for 
gonorrhea,  they  should  be  stopped.  Some  urinary  antiseptic  should 
be  given.  Puncture  of  the  tense  tunica  albuginea  in  one  or  several 
places,  with  a  fine  tenotome,  is  the  most  efficient  way  of  relieving 
pain.    No  anesthetic  is  required.    The  scrotum  is  painted  with  2  per 


Fig.  1069. — Orchitis  following  mumps.  Age 
fourteen  years.  Mumps  one  week  ago,  followed 
first  by  left  orchitis,  which  subsided;  then  by 
right  orchitis,  which  has  lasted  for  three  days. 
Episcopal  Hospital. 


1110  SURGERY  OF  THE  MALE  GENITAL  ORGANS 

cent,  iodin  solution,  and  is  drawn  tensely  over  the  testicle,  and  the 
puncture  is  made  at  the  seat  of  greatest  swelling.  This  plan  is  said 
to  have  been  suggested  by  Petit,  and  widely  employed  by  Vidal  de 
Cassis,  and  by  II.  Smith,  during  the  last  century.  As  an  open  oper- 
ation the  method  has  been  recently  revived  by  Hagner  (1908),  Cook 
(1918),  and  -lames  (1919);  for  this,  a  general  anesthetic  is  advisable: 
Incise  the  scrotum,  deliver  the  testicle,  puncture  and  evacuate  the 
acute  hydrocele;  then  incise  the  tunica  albuginea  not  across  the  cavity 
of  the  tunica  vaginalis,  but  by  the  retrovaginal  route;  separate  the 
tunica  albuginea  from  the  epididymis,  thrust  a  dull  probe  into  the 
hard  areas  in  the  latter,  and  suture  a  drain  tube  beneath  the  tunica 
albuginea;  do  not  drain  the  tunica  vaginalis.  The  operation  relieves 
pain,  prevents  complications,  and  perhaps  reduces  the  liability  to 
sterility.  Recurrences  have  not  been  noted  If  no  operation  is  done 
acute  symptoms  persist  for  four  or  five  days;  then  sorbefacient  oint- 
ments, especially  those  containing  guaiacol  and  ichthyol,  should  be 
applied,  and  when  only  a  painless  induration  remains,  resolution 
may  be  favored  by  strapping  the  testicle  with  adhesive  plaster.  In  the 
most  acute  cases  of  gonorrheal  epididymitis  suppuration  may  occur, 
requiring  incision  and  drainage  of  an  abscess;  occasionally  castration  is 
required.  In  almost  all  cases  cicatricial  changes  occur  in  the  body 
or  globus  minor  of  the  epididymis,  which  prevent  discharge  of  semen 
into  the  vas  deferens;  and  if  both  sides  have  been  affected  the  patient 
may  be  rendered  sterile.  To  overcome  this  condition,  which  is  said 
to  occur  in  about  40  per  cent,  of  cases  of  bilateral  epididymitis,  Edward 
Martin  (1902)  has  practised  with  success  an  anastomosis  between  the 
globus  major  and  the  vas  deferens  (epididymo-vasostomy).  Cases  of 
recurrent  epididymitis  often  are  caused  by  infection  from  the  seminal 
vesicles,  and  can  be  cured  only  by  proper  treatment  of  this  focus  of 
infection. 

Neuralgia  of  the  Testicle. — Under  this  name  is  described  a  condi- 
tion in  which  the  testicle,  usually  the  left,  is  persistently  tender  and 
afflicted  with  lancinating  pains.  This  condition  must  be  distinguished 
from  referred  pain  due  to  lesions  elsewhere,  notably  renal  calculus 
and  varicocele.  If  no  cause  for  referred  pain  exists,  and  a  history  of 
epididymitis,  or  orchitis  is  obtained,  it  is  probable  that  the  neuralgia 
is  due  to  compression  of  the  testicle  by  sclerosis  and  contraction  of 
the  tunica  vaginalis  or  albuginea;  under  such  circumstances  continu- 
ance of  palliative  measures  (use  of  a  suspensory,  hot  and  cold  douches, 
occasional  passage  of  a  cold  sound,  or  instillations  of  argyrol  into  the 
deep  urethra,  etc.)  probably  will  prove  useless,  and  it  is  best  to  expose 
the  testicle  and  excise  the  tunica  vaginalis. 

Semino-vesiculitis  or  Spermato-cystitis. — This  may  be  acute  or 
chronic.  The  acute  form  almost  invariably  occurs  as  a  complication 
of  gonorrhea.  Chronic  semino-vesiculitis  usually  is  a  sequel  of  the 
acute  form,  but  the  condition  may  be  chronic  from  the  start  and  may 
be  due  not  to  gonorrhea  but  to  non-gonococcic  posterior  urethritis  or 
prostatitis.    In  most  cases  only  one  vesicle  is  affected  at  first,  but 


TUBERCULOSIS  OF  THE  TESTICLE  1111 

the  second  rarely  escapes  eventual  infection.  In  the  acute  form  the 
vesicle  is  distended  with  purulent  exudate,  but  inflammatory  infil- 
tration of  surrounding  tissues  may  occur  to  such  a  degree  that  the 
vesicles  cannot  be  recognized  by  palpation  through  the  rectum.  The 
symptoms  of  the  acute  form  are  pain  in  the  perineum  or  rectum, 
especially  after  defecation  or  seminal  ejaculation.  The  semen  often  is 
blood-stained,  and  may  be  colored  blue  from  the  admixture  of  indigo. 
Sexual  excitability  is  pronounced,  and  frequent  and  painful  erections 
are  characteristic.  In  the  chronic  form  the  symptoms  are  those  of 
the  gleet  (p.  10G6);  recurrent  attacks  of  epididymitis  often  occur. 

Treatment. — In  acute  semino-vesiculitis  the  patient  should  be  con- 
fined to  bed,  and  all  local  treatment  of  the  urethral  condition  should 
be  discontinued.  A  hot  water  bag  may  be  applied  to  the  perineum, 
or  hot  rectal  injections  may  be  given  if  they  lessen  discomfort.  Urinary 
antiseptics  should  be  given,  and  the  bowels  should  be  opened  by  a 
laxative.  If  pain  is  excessive,  and  particularly  if  constitutional  symp- 
toms exist,  the  occurrence  of  suppuration  should  be  suspected:  the 
patient  then  should  be  anesthetized  and  the  rectum  explored;  if  any 
signs  indicating  suppuration  are  found,  the  vesicle  should  be  exposed 
through  the  perineum  (by  the  method  advised  for  perineal  prosta- 
tectomy), or  by  suprapubic  (extraperitoneal)  incision,  and  opened  and 
drained.  The  treatment  of  chronic  seminovesiculitis  has  already 
been  considered  in  connection  with  chronic  urethritis.  In  cases 
of  recurrent  epididymitis,  Belfield  opens  the  vas  deferens  below  the 
external  abdominal  ring  and  irrigates  the  seminal  vesicle  by  injecting 
not  more  than  2  c.c.  of  the  irrigating  fluid.  As  noted  at  p.  514,  Fuller 
drained  the  seminal  vesicles  through  the  perineum  in  cases  of  gonococcic 
arthritis. 

Tuberculosis  of  the  Testicle. — This  is  believed  to  be  due  in  most 
cases  to  hematogenous  infection.  Keyes,  however,  maintains  that 
it  is  always  secondary  to  tuberculosis  of  the  prostate  and  seminal 
vesicles,  and  it  is  possible  that  future  studies  may  show  it  usually  to 
be  due  to  descending  infection  from  the  kidney.  The  lesion  in  the 
testicle  begins  in  the  globus  major  of  the  epididymis1  and  invades 
the  testis  secondarily.  The  patients  usually  are  between  twenty 
and  thirty  years  of  age,  and  as  a  rule  only  one  testicle  is  affected  at 
first,  but  extension  to  the  other  side  is  frequent,  probably  by  way  of 
the  seminal  vesicles  and  ejaculatory  ducts  through  the  vas  deferens. 

Symptoms. — The  onset  usually  is  insidious,  and  the  patient  may  be 
scarcely  aware  of  his  condition  until  he  discovers  by  accident  a  hard 
nodule  in  the  epididymis,  or  until  suppuration  has  occurred  with 
fistulization  of  the  scrotum.  In  the  rare  cases  with  acute  onset 
the  condition  at  first  somewhat  resembles  gonorrheal  epididymitis; 
but  unlike  this  affection  it  does  not  subside  in  the  course  of  a  week 
or  two.  In  most  cases  the  clinical  diagnosis  must  be  considered 
uncertain  until  areas  of  softening  have  formed;  usually  this  is  quickly 

1  In  gonococcic  epididymitis  the  globus  minor  is  attacked  before  the  globus  major. 


1112 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


Fig.  1070. — Tuberculosis  of  both  tes- 
ticles, duration  four  months;  age  nine- 
teen years.  Right  testicle  adherent  to 
skin,  and  abscess  palpable.  Both 
seminal  vesicles  enlarged  and  nodular. 
Episcopal  Hospital. 


followed  by  implication  of  the  skin  of  the  scrotum,  which  becomes 
adherent  to  the  testicle  (Fig.  1070) ;  then  the  cold  abscess  ruptures 
and  cheesy  pus   is  constantly  discharged  from  the  fistula  (Fig.  1071). 

At  this  stage  the  diagnosis  may  be 
confirmed  by  finding  tubercle  bacilli 
in  the  discharge;  at  earlier  stages 
focal  reaction  to  a  tuberculin  test 
may  be  relied  on. 

Treatment. — There  is  much  dis- 
pute among  surgeons  as  to  the 
proper  treatment  of  these  patients. 
Some  advise   immediate  castration 

^in  all  cases ;  others  condemn  all  oper- 
ative interference  and  trust  entirely 
to  hygienic  measures  and  vaccine 
therapy.  My  own  feeling  is  that 
so  long  as  suppuration  and  fistuli- 
zation  do  not  occur  there  is  no  need 
j  to  remove  the  testicle.  A  nodule 
in  the  epididymis  may  remain 
unchanged  for  years  provided  ex- 
cellent hygienic  life  conditions  are 
present,  as  has  been  shown  by  Wat- 
son and  Cunningham.  Under  such 
circumstances  (and  if  tuberculous 
lesions  exist  elsewhere  in  the  body,  even  if  the  local  lesion  is  advanced) 
minor  operative  measures  may  be  of  benefit  to  the  local  condition  and 
may  promote  the  patient's  comfort.  Epididymectomy  sometimes  is 
done,  leaving  the  testis  intact,  with  or  without  anastomosis  between 
it  and  the  vas  deferens.  Ac- 
cording to  Barney  (1911)  the 
semen  is  sterile  in  So  per  cent, 
of  patients  even  before  epididy- 
mectomy. A  cold  abscess  may 
be  treated  on  the  same  princi- 
ples recommended  when  deal- 
ing with  cold  abscesses  in  asso- 
ciation with  bone  disease.  But 
when  fistulization  has  occurred, 
and  particularly  if  secondary 
infection  is  present,  I  feel  quite 
sure  it  is  best,  especially  in  the 
average  hospital  patient,  to  re- 
move the  testicle  and  spermatic 
cord  as  far  as  the  internal  ring. 

The  operation  is  described  below.  If  only  one  testicle  is  diseased  and 
is  removed,  only  about  9  per  cent,  of  patients  die  of  genito-urinary 
tuberculosis,  the  other  testicle  becomes  involved  subsequently  only  in 


Fig.  1071. — Tuberculosis  of  left  testicle, 
duration  two  years;  age  thirty-three  years. 
Operation  for  left  hydrocele  eighteen  months 
ago;  fistula?  in  scrotum  for  last  six  months. 
(See  Fig.  1072.)     Episcopal  Hospital. 


SARCOCELE 


1113 


about  26  per  cent.,  and  cure  follows  in  about  45  per  cent,  of  patients; 
if  double  castration  is  necessary,  15  per  cent,  of  patients  die  within 
the  first  three  years  after  operation,  but  56  per  cent,  are  permanently 
cured  (Haas,  1901). 

Castration  or  Orchidectomy—  Open  the  inguinal  canal,  as  in  the 
operation  for  hernia.  Transfix  and  ligate  the  spermatic  cord  at  the 
internal  abdominal  ring.  Cut  the  cord  below  the  ligature  and  turn 
it  down  over  the  scrotum  with  its 
annexed  fatty  tissue  and  lymph 
nodes.  Close  the  inguinal  wound 
(except  at  the  lower  angle  where 
the  cord  emerges)  as  in  the  oper- 
ation for  hernia,  and  cover  it  with 
sterile  gauze.  Then  proceed  to  re- 
move the  testicle  in  one  mass  with 
the  adherent  scrotum,  by  extend- 
ing the  original  incision  downward, 
cutting  wide  of  all  infiltrated  tissue. 
In  this  way  the  inguinal  wound  runs 
no  risk  of  being  infected,  since  it  is 
closed  before  the  suppurating  scrotal 
tissues  are  attacked,  and  all  the  dis- 
eased tissue  is  removed  in  one  mass. 
Usually  it  is  well  to  leave  a  small 
drain  in  the  scrotal  end  of  the  incis- 
ion for  a  couple  of  days. 

Syphilis  of  the  Testicle.  —  Sarco- 
cele.1 — Sarcocele  is  a  manifestation 
of  the  third  stage  of  syphilis.  The 
lesion  almost  always  is  in  the  tes- 
tis, not  in  the  epididymis;  the 
most  frequent  form,  clinically,  is  a 
gummatous  deposit  in  one  or  sev- 
eral spots.  Pathologically  a  diffuse 
sclerosis  of  the  tunica  albuginea  and  septa  of  the  testis  is  a  very  fre- 
quent lesion,  but  it  is  seldom  recognized  clinically.  In  most  cases 
of  the  gummatous  form  of  the  disease  only  one  testis  is  involved; 
softening  of  the  gumma  with  ulceration  of  the  skin  scarcely  ever 
occurs.  The  affection  is  extremely  indolent.  The  testicle  grows 
slowly  and  never  reaches  a  very  large  size ;  it  presents  smooth,  rounded 
nodules  almost  of  woody  hardness  and  not  at  all  tender.  If  the 
epididymis  is  involved,  the  testis  feels  like  a  stone  lying  in  a  clam  shell, 
the  sharp  edges  of  the  hardened  epididymis  embracing  the  testis  (Keyes). 
Frequently  a  hydrocele  of  the  tunica  vaginalis  is  present.  The  only 
subjective  symptoms  are  those  due  to  the  increased  weight  of  the 
organ.    A  history  of  syphilis  usually  can  be  obtained;  the  Wassermann 

1  This  is  an  old  term  still  in  use,  signifying  a  fleshy  or  solid  tumor;  by  long  usage 
it  is  applied  exclusively  to  enlargements  of  the  testicle  (syphilitic  or  neoplastic). 


Fig.  1072. — Specimen  removed  by 
castration  from  the  patient  shown  in 
Fig.  1071 :  testicle  and  adherent  skin 
of  scrotum,  with  spermatic  cord  and 
inguinal  lymph  nodes  in  one  mass. 
Episcopal  Hospital. 


1114 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


test  will  be  positive;  and  antisyphilitic  treatment  will  prove  rapidly 
curative.     The  diagnosis  must  be  made  from  tuberculosis  and  from 


Fig.  1073. — Scars  from  double  orchidec- 
tomy  for  tuberculous  sarcocele.  Age  forty- 
six  years.     Episcopal  Hospital. 


Fig.  1074.  —  Syphilitic  sarcocele. 
Age,  fifty  years;  duration,  two  years. 
Chancre  twenty  yeais  ago.  Scar  from 
suprapubic  prostatectomy.  Episcopal 
Hospital. 


tumors  of  the  testicle.    In  the  former  the  epididymis  is  affected,  and 
invasion  and  fistulization  of  the  skin  are  frequent.     In  the  latter,  most 

of  which  are  instances  of  malig- 
nant disease,  the  testicle  grows 
rapidly,  attains  a  much  greater 
size  than  in  syphilis,  there  is 
more  pain  and  discomfort, 
and  invasion  of  the  skin  is 
frequent,  with  the  protrusion 
of  a  fungus  growth. 

Treatment. — In  every  case  of 
sarcocele,  where  the  diagnosis 
is  doubtful,  it  is  well  to  try 
antisyphilitic  treatment  be- 
fore any  operation  is  recom- 
mended. If  the  disease  is 
syphilitic,  mixed  treatment 
will  be  quickly  effectual. 
Neoplasms  of  the  Testicle  are  not  very  rare,  except  benign  tumors. 
Most  of  the  tumors  are  extremely  malignant,  and  are  classed  loosely 
as  sarcomas.  Chevassu  (1910),  in  a  careful  study  of  100  cases,  found 
carcinoma  (seminoma)  in  47,  true  sarcoma  in  3,  and  mixed  tumors  in 
50  cases.  Such  tumors  may  occur  at  any  age,  but  are  most  frequent 
in  middle  life.  Growth  is  rapid  (weeks),  and  the  tumor  may  become 
several  times  as  large  as  the  normal  testicle.    In  most  cases  hydrocele 


Fig.  1075. — Sarcoma  of  right  testicle.  Age 
seventy-four  years,  duration  five  months. 
Diagnosis  made  after  tapping  hydrocele 
(125  c.c.  of  bloody  fluid),  which  permitted  pal- 
pation of  hard  nodular  growths.  Episcopal 
Hospital. 


HYDROCELE 


1115 


of  the  tunica  vaginalis  develops,  and  its  contained  fluid  usually  is 
blood-stained  (Fig.  1075) :  if  there  is  no  history  of  injury  the  presence 
of  blood  in  hydrocele  fluid  always  suggests  malignancy.  Extension 
occurs  early  along  the  spermatic  cord,  and  to  the  lumbo-aortic 
lymph  nodes,  and  especially  to  a  lymph  node  at  the  bifurcation  of 
the  common  iliac  vein. 

Treatment. — By  the  ordinary  method  of  castration,  as  described 
in  connection  with  tuberculosis  of  the  testicle,  surgery  succeeds  in 
saving  about  20  per  cent,  of  patients.1  Radical  operation  implies  re- 
moval of  the  tumor  in  one  mass  with  its  anatomically  related  lymph 
nodes.  Chevassu  (1910)  devised  a  technique  by  which  the  lumbo-aortic 
nodes  may  be  reached:  the  incision  passes  along  the  inguinal  canal 
and  up  the  abdominal  wall  outside  the  semilunar  line  as  far  as  the 
false  ribs,  and  if  necessary  is  extended  forward  along  the  costal  border. 
The  parietal  peritoneum  is  dissected  inward,  without  opening  the 
peritoneal  cavity,  and  when  the  perirenal  fascia  is  reached  its  anterior 
layer  is  incised,  and  the  dissection  continued  in  front  of  the  kidney, 
until  the  renal  vessels  and 
aorta  are  exposed.  In  1910 
Chevassu  collected  records 
of  11  such  operations,  with 
no  immediate  mortality;  in 
8  the  operation  was  carried 
to  a  successful  conclusion, 
but  in  3  others  had  to  be 
abandoned  (inoperable). 

Hydrocele. — This  is  a  col- 
lection of  serous  fluid  in  the 
tunica  vaginalis. 

In  congenital  hydrocele 
(Fig.  1076)  there  is  a  com- 
munication between  the  tu- 
nica vaginalis  and  the  peri- 
toneal cavity.  Usually  the  orifice  of  communication  is  too  small  for 
the  development  of  a  hernia.  The  condition  is  noted  first  in  infancy, 
but  may  persist  until  adult  life,  even  without  the  development  of  a 
hernia.  When  the  scrotum  is  elevated  the  fluid  disappears  within  the 
abdominal  cavity,  usually  very  slowly,  and  as  slowly  reappears  when 
the  erect  posture  is  resumed.  Treatment  is  the  same  as  for  inguinal 
hernia  in  infants. 

Acquired  Hydrocele  of  the  tunica  vaginalis  is  seen  oftenest  in  child- 
hood and  in  middle  adult  life  (Figs.  1077  and  1078).  The  pathogenesis 
of  the  lesion  is  uncertain,  but  the  fluid  probably  is  in  the  nature  of  an 


Fig.  1076. — Congenital  hydrocele  (left).    Age  five 
months.     Children's  Hospital. 


1  Out  of  100  patients  with  malignant  disease  of  the  testicle  treated  by  the  ordinary 
method  of  castration,  Chevassu  found  81  died  in  less  than  four  years,  while  19 
survived  in  good  health  for  periods  varying  from  four  to  ten  years  after  operation. 


1110 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


Fig.  1077. — Hydrocele  of  the  right  tunica 
vaginalis,  in  a  child  of  three  years.  Chil- 
dren's Hospital. 


exudate,  due  to  trauma  or  some  form'of  infection  of  low  grade.     As 
already  mentioned,  gonorrheal  epididymitis  and  most  other  infections 

of  the  testicle  are  accompanied 
1  >y  the  development  of  acute  hy- 
drocele, and  such  a  lesion  may 
lay  the  foundation  for  the  sub- 
sequent pathological  change  in 
the  serous  membrane  which 
leads  to  chronic  serous  effusion. 
It  is  probable  that  many  adult 
hydroceles  are  unrecognized 
manifestations  of  tuberculosis 
(Fig.  1071)  or  syphilis.  In  some 
cases  rice. bodies  are  found,  and 
the  sac  may  become  calcareous. 
Most  of  the  adults  affected  are 
arteriosclerotic. 
Symptoms. — The  swelling  commences  at  the  bottom  of  the  scrotum, 
and  gradually  increases  in  size.  At  first  it  is  soft  and  fluctuating, 
but  eventually  may  become  very  tense  and  hard.  The  patient  has 
little  or  no  discomfort  except  from  the  size  and  weight  of  the  swelling. 
Usually  relief  is  sought  before  a  very  great  size  is  attained.  Rarely 
the  sac  extends  into  the  inguinal  canal,  and  from  the  existence  of  con- 
strictions (similar  to  those 
encountered  in  some  cases  of 
inguinal  hernia — see  p.  831) 
an  hour-glass  or  bilocular  hy- 
drocele may  result  (Fig.  1079). 
The  same  appearance  may  be 
caused  by  the  coexistence  of 
a  vaginal  hydrocele  and  a 
hydrocele  of  the  cord. 

The  diagnosis  is  made  from 
the  history  of  the  case,  and 
from  observing  that  most  hy- 
droceles are  translucent  when 
examined  by  transmitted  light; 
old  hydroceles,  with  thickened 
walls,  and  those  into  which 
hemorrhage  has  occurred, 
however,  are  opaque.  The  diagnosis  from  hernia  was  considered 
at  p.  835. 

The  best  treatment  is  by  operation;  but  in  adults  who  refuse  operation 
or  in  whom  operation  is  contraindicated  for  any  reason,  it  is  sufficient 
to  withdraw  the  fluid  from  time  to  time  by  tapping  the  hydrocele. 
The  testicle  almost  always  is  at  the  back  part  of  the  swelling,  but  its 
position  should  be  ascertained  by  palpation  and  by  examination  with 


Fig.  1078. — Hydrocele  of  tunica  vaginalis. 
Age  fifty-two  years;  duration  nine  years; 
tapped  eight  times.  One  liter  withdrawn 
after  making  photograph.    Episcopal  Hospital. 


SPERMATOCELE 


1117 


-Bilocular  hydrocele. 
Age  twenty-three  years;  duration 
since  infancy.  (Dr.  C.  F.  Mitchell's 
case.)     Pennsylvania  Hospital. 


transmitted  light.  The  tumor  is  then  grasped  in  the  left  hand,  and 
the  skin  is  drawn  tightly  over  it,  when  with  a  quick  thrust  a  trocar 
and  cannula  are  pushed  into  the  most 
prominent  part  of  the  swelling,  avoid- 
ing large  veins.  The  trocar  is  then 
withdrawn  and  the  contents  of  the 
hydrocele  allowed  to  flow.  When  all 
the  fluid  has  been  evacuated  the  can- 
nula is  withdrawn  and  the  puncture  is 
sealed  with  cotton  and  collodion.  No 
anesthetic  is  required  and  the  patient 
need  not  be  confined  to  bed.  He  should 
wear  a  close-fitting  suspensory  in  an 
endeavor  to  prevent  too  rapid  re-ac- 
cumulation of  the  fluid.  It  is  well  to 
examine  the  testicle  carefully  after  the 
hydrocele  fluid  has  been  evacuated, 
as  in  many  cases  it  is  found  diseased. 
Some  surgeons  recommend  the  injec- 
tion into  the  emptied  sac  of  some 
irritating  or  caustic  fluid  in  the  hope 

of  causing  obliteration  of  the  cavity;  but  the  alleged  advantages  of 
this  practice  do  not  compensate  for  the  dangers  of  uncontrollable 
inflammation  and  excessive  pain.  In  most  cases  in  which  simple  tap- 
ping is  done,  re-accumulation  of  the  fluid  occurs  at  progressively 
shorter  intervals. 

Operation. — In  most  cases,  especially  in  children  and  young  adults, 
it  is  best  to  resort  to  operation.  The  incision  should  be  made  just 
below  the  external  abdominal  ring,  not  in  the  scrotum,  as  this  is  diffi- 
cult to  sterilize.  The  operation  of  Jaboulay  (1895)  consists  in  evacu- 
ating the  contents  of  the  sac  by  incision,  and  everting  the  walls  of  the 
tunica  vaginalis  around  the  testicle  so  that  the  serous  surface  of  the 
tunica  vaginalis  lies  against  the  subcutaneous  tissues.  Recurrences  are 
frequent  after  this  operation;  therefore  excision  of  the  sac  (von  Berg- 
mann)  is  preferable.  It  is  well  to  scarify  the  testicular  portion  of  the 
tunica  vaginalis  with  the  scalpel  to  destroy  its  secretory  surface. 

Hydrocele  of  the  Cord  is  a  collection  of  serous  fluid  in  an  unoblit- 
erated  portion  of  the  funicular  process  of  peritoneum.  If  the  sac 
communicates  with  the  peritoneal  cavity,  the  condition  is  known  as 
funicular  hydrocele;  if  the  sac  is  closed  at  both  ends,  it  is  an  encysted 
hydrocele  of  the  cord  (Fig.  1080) .  Hydrocele  of  the  canal  of  Nuck  is  the 
corresponding  condition  in  the  female  sex.  If  inflammation  of  the  sac 
occurs  from  any  cause,  and  no  accurate  history  can  be  obtained,  the 
condition  may  be  readily  mistaken  for  strangulated  hernia.  Treat- 
ment of  hydrocele  of  the  cord  consists  in  excision  of  the  sac. 

Spermatocele. — Spermatocele,  known  also  as  encysted  hydrocele  of  the 
tunica  vaginalis,  is  a  cyst  which  develops  about  the  globus  major 
of  the  epididymis   and  contains  spermatic  fluid.  Its  pathogenesis  is 


ins 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


Fig.  1080. — Encysted  hydrocele  of 
the  cord.  Age  two  and  a  half  years. 
( 'hildren's  Hospital. 


disputed  (Crossan,   1920).     It  occurs  oftenest  in  young  adults,  and 
forms  a  slowly  growing  but  tense  cystic  tumor  at  the  upper  and  back 

part  of  the  testicle.  It  may  project 
into  the  tunica  vaginalis  or  grow  be- 
hind it.  The  diagnosis  often  is  not 
made  until  operation  is  done.  Proper 
treatment  is  excision  of  the  sac. 

Hematocele. — A  collection  of  blood 
in  the  tunica  vaginalis  may  result 
from  injury  or  disease;  there  may  or 
may   not   have  been    a   preexisting 
hydrocele.     In  many  cases  seemingly 
of  spontaneous  origin,  hematocele  is 
symptomatic  of   malignant   disease 
of  the  testicle.    The  physical   signs 
are  the  same  as  those  of  vaginal  hy- 
drocele, except  that  the  swelling  is 
opaque  to  transmitted  light. 
Treatment. — In  acute  traumatic  cases  the  blood  should  be  with- 
drawn by  tapping.     In  other  cases  the  treatment   is  that  of  the 
underlying  cause  (hydrocele,  sarcocele). 

Varicocele. — A  varicose  condition  of  the  veins  of  the  spermatic 
cord  (the  pampinniform  plexus)  occurs  in  about  10  per  cent,  of  males, 
usually  commencing  about  the  age  of  puberty.  In  almost  all  cases 
the  left  side  is  affected,  occasionally  both  sides,  very  seldom  the  right 
alone.  This  predilection  for  the  left  side  is  attributed  (1)  to  the  pres- 
sure of  the  sigmoid  on  the  spermatic  vein;  (2)  to  the  fact  that  the  left 
spermatic  vein  enters  the  left  renal  at  a  right  angle,  while  the  right 
spermatic  enters  the  vena  cava  obliquely;  (3)  to  the  absence  of  valves 
on  the  left  side;  (4)  to  the  lower  position  of  the  left  testicle  in  the 
scrotum;  and  (5)  to  the  habit  most  men  have  of  "dressing  left." 
Seldom  or  never  can  any  exciting  cause  be  found.  The  rather  rapid 
onset  of  a  varicocele  usually  is  symptomatic  of  some  abdominal 
neoplasm  obstructing  the  venous  circulation. 

Symptoms. — Symptoms  may  be  entirely  absent  even  in  cases  where 
the  varicocele  is  very  large.  Often,  however,  the  patient  complains 
of  vague  dragging  pains  and  discomfort  in  the  left  side  of  the  scrotum, 
and  there  may  be  occasional  lancinating  pains  in  the  testicle  and  along 
the  cord.  Atrophy  of  the  testicle  is  mentioned  as  a  possible  sequel, 
but  I  never  observed  it.  In  rare  cases  the  patient  may  be  "neuras- 
thenic." Examination  showrs  a  relaxed  state  of  the  scrotum,  with 
the  left  testicle  hanging  very  low,  and  above  it,  extending  up  to  the 
inguinal  canal,  a  soft  mass  of  dilated  veins  wThich  feel  like  a  bunch 
of  earthworms  (Fig.  1081).  These  veins  may  be  emptied  by  having 
the  patient  lie  dowrn  and  elevating  the  scrotum;  they  will  become 
distended  again  when  he  stands  up,  even  if  pressure  is  made  over  the 
inguinal  canal. 


TUMORS  OF   THE  SCROTUM 


1119 


Treatment. — Treatment  seldom  is  required.  There  is  nothing  serious 
in  the  condition  and  it  often  disappears  spontaneously  later  in  life. 
If  the  patient  is  uncomfortable  he  will  feel  better  for  wearing  a  sus- 
pensory bandage,  particularly  in  warm  weather,  and  in  "dressing  right." 
Cold  douches  sometimes  are  soothing.  If  marked  discomfort  persists, 
the  varicocele  is  easily  cured  by  a  simple  operation.  An  incision  is 
made  at  the  external  abdominal  ring,  and  the  cord  is  brought  out  of  the 
wound.  The  dilated  veins  are  separated  from  the  vas  deferens  and  its 
accompanying  vessels,  and  the  varicose  veins  are  ligated  close  to  the 
external  ring,  and  again  about  5  cm .  lower.  The  ends  of  these  ligatures 
are  left  long,  and  after  the  section  of  veins  lying  between  the  ligatures 
has  been  removed,  the  ligature  on  the  proximal  end  is  tied  to  that  on 
the  scrotal  end  of  the  cord,  thus  shortening  the  cord  and  elevating 
the  testicle.  The  wound  is  closed  without  drainage  (careful  henio- 
stasis),  and  the  patient  stays  in  bed  a  week  or  ten  days. 


Fig.  1081. — Varicocele,  age  thirty-six  years.     Episcopal  Hospital 


Elephantiasis. — Elephantiasis  occurs  oftenest  in  the  scrotum,  as 
pointed  out  in  Chapter  XI,  and  the  disease  may  spread  thence  to  the 
penis.  As  the  result  of  lymphatic  obstruction  and  repeated  attacks 
of  dermatitis,  the  skin  and  subcutaneous  tissues  become  enormously 
hypertrophied,  deep  creases  and  folds  form,  and  in  them  dirt  and 
macerated  epithelial  cells  collect,  emitting  nauseating  odors,  and  pre- 
disposing to  ulceration  and  renewed  attacks  of  dermatitis,  eczema, 
erysipelas,  etc.  In  tropical  countries  the  scrotum  may  become  so 
immense  that  the  patient  has  to  push  it  around  before  him  on  a  wheel- 
barrow. In  this  latitude  the  disease  is  very  seldom  seen.  The  best 
treatment  is  excision.  The  operation  may  prove  difficult,  and  bleed- 
ing usually  is  free;  but  if  asepsis  can  be  maintained,  great  relief  is 
afforded. 

Tumors  of  the  Scrotum  are  unusual.  The  occurrence  of  dermoids 
(sequestration  cysts)  was  mentioned  in  Chapter  IV  (Fig.  81). 
Papillomas  are  more  frequent,  and  often  undergo  malignant  degen- 
eration (Fig.  1082).     In  former  years  epithelioma  of  the  scrotum  was 


1120 


Kl'KCKKY  OF  THE   MALE  GENITAL  ORGANS 


frequently  seen  in  chimney  sweepers,  from  the  irritation  of  the  soot 
which  accumulated  on  the  scrotum  in  these  persons  of  none  too  cleanly 
habits.    At  the  present  day  workers  in  tar  and  paraffin  are  subject 


Fig.  1082. — Ulcerating  papilloma  of  scrotum  (epitheliomatous).     Age  thirty-six 
years;  duration  three  and  a  half  years.     Episcopal  Hospital. 


to  the  same  affection.  The  proper  treatment  of  these  tumors  is 
excision;  this  scarcely  ever  requires  castration,  as  the  malignant 
growth  spreads  widely  in  the  skin  before  attacking  the  testicles. 


CHAPTER  XXIX. 

SURGERY  OF  THE  FEMALE  GENITALS. 

General  Remarks  on  Examination  of  the  Female  Pelvic  Organs. 
— Position  of  the  Patient.  —  The  woman  usually  is  examined  in  the 
"lithotomy  position,"  that  is,  lying  on  her  back,  with  knees  and  hips 
flexed,  and  the  soles  of  the  feet  resting  on  the  bed  or  table  where  she 
lies  (Fig.  1083).  Sometimes  the  "Sims  position"  is  preferred:  here  the 
woman  lies  on  her  left  side,  with  her  left  arm  behind  her  back,  thus 
throwing  her  right  shoulder  forward;  her  right  thigh  is  flexed  upon 
her  abdomen  as  fully  as  possible,  so  that  the  right  knee  rests  upon 
the  table,  while  the  left  lower  extremity  is  flexed  only  to  a  moderate 


Fig.  1083. — Lithotomy  position. 

degree  (Fig.  1084).  Sometimes,  but  not  very  often,  it  is  desirable  to 
examine  the  patient  in  the  standing  position,  or  even  in  the  knee- 
chest  position  (Fig.  1085).  In  a  virgin,  vaginal  examination  should 
be  made  only  when  the  patient  is  under  the  influence  of  a  general 
anesthetic.     A  rectal  examination  may  suffice. 

An  examination  of  the  female  pelvic  organs  should  include  (1) 
inspection  of  the  external  genitalia,  (2)  examination  with  the  speculum, 
and  (3)  bimanual  examination  of  the  internal  genital  organs.  The 
bladder  and  rectum  should  be  empty. 

71  (1121) 


1122 


SURGERY  OF   THE  FEMALE  GENITALS 


External  Genitalia. — Note  the  condition  of  the  labia:  inflammatory 
changes,  as  in  acute  gonococcic  vulvitis  and  vaginitis;  the  existence 
of  a  labial  abscess;  the  presence  or  absence  of  mucous  patches;  edema 
from  pregnancy  or  pelvic  tumors;  excoriations  and  hypertrophy  in 
cases  of  pruritus.    Observe  the  state  of  the  hymen;  the  position  of  the 


Fig.  1084. — Sims's  position. 


carunculse  myrtiformes,  if  present;  and  the  condition  of  the  vulvar 
opening,  whether  normally  closed  or  widely  gaping  as  in  multiparous 
patients  with  relaxed  vaginal  outlet.  The  position  and  condition  of 
the  urethral  orifice  should  be  noted,  especially  the  presence  of  a 
gonorrheal  discharge,  or  the  existence  of  a  caruncle. 


Fig.  1085. — Knee-chest  position. 

Speculum  Examination. — If  the  patient  is  in  the  Sims  position,  the 
duck-bill  vaginal  speculum  of  Sims  (1845)  should  be  used  (Fig.  1086,  2). 
This  is  inserted  with  the  blade  in  the  sagittal  plane,  and  as  soon  as 
the  vagina  is  entered  the  blade  is  turned  transversely,  and  is  pushed 
forward  until  the  stem  catches  on  the  fourchette;  then  the  speculum  is 
drawn  backward,  displacing  the  posterior  vaginal  wall  and  rectum  into 
the  hollow  of  the  sacrum,  and  causing  the  vagina  to  be  ballooned  with 
air.  This  usually  renders  the  cervix  visible.  In  the  dorsal  and  lithotomy 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS       1123 

positions  it  is  more  convenient  to  use  a  bivalve  speculum  (Fig.  1086, 1) : 
this  is  inserted  closed,  with  the  blades  in  the  sagittal  plane;  as  soon 


Fig.  1086. — 1,  Bivalve  vaginal  speculum.     2,  Sims's  duck-bill  speculum. 
3,  Speculum  forceps. 


Fig.  1087. — 1,  uterine  sound.     2,  sharp  uterine  curette.     3,  dull  uterine  curette. 
4,  placental  forceps.     5,  double  tenaculum  forceps.     6,  cervical  dilator. 


1124 


Sl'RGERY  OF   THE  FEMALE  GENITALS 


as  the  vagina  is  entered  the  speculum  is  turned  transversely,  but 
the  blades  are  not  opened  until  the  speculum  has  entered  its  full 
length.  When  the  blades  are  finally  separated,  the  surgeon  endeavors 
to  bring  the  cervix  into  view  between  them.  If  the  speculum  is  too 
small  or  too  short  this  may  prove  difficult.  Several  sizes  should  be 
available.     When  the  cervix  is  exposed,  examine  its  size,  its  shape, 


Fig.  1088. — Bimanual  vaginal  examination.     (Dudley.) 

and  its  position;  note  the  presence  or  absence  of  lacerations,  erosions, 
ulcerations;  observe  the  condition  of  the  os,  whether  characteristic 
of  a  nulliparous  or  parous  patient;  and  especially  note  the  presence 
or  absence  of  a  cervical  discharge  and  its  character — mucous,  purulent, 
bloody,  etc.  In  suspicious  cases  smears  should  be  taken  from  vagina, 
from  urethra,  and  from  cervix  for  microscopical  examination. 


CONGENITAL  MALFORMATIONS  1125 

Bimanual  Examination. — After  withdrawing  the  speculum,  insert 
two  fingers  of  the  gloved  hand  into  the  vagina.  The  beginner  will 
do  best  to  use  both  right  and  left  hands,  alternately,  on  the  same 
patient;  with  the  left  hand  he  will  be  able  to  feel  lesions  on  the  left 
side  of  the  pelvis  which  might  easily  escape  detection  if  the  right  hand 
only  was  used.  First  examine  the  condition  of  the  posterior  vaginal 
wall  and  perineum.  Then  locate  the  cervix,  and  note  its  condition 
(soft  and  characteristic  of  pregnancy;  hard,  with  scar  tissue  from 
previous  pregnancies,  lacerations,  etc.),  its  size,  its  position  (whether 
or  not  displaced  by  pelvic  lesions),  and  its  mobility,  or  fixation.  With 
the  aid  of  the  other  hand  above  the  pubes  (Fig.  10SS),  then  endeavor  to 
palpate  the  fundus  of  the  uterus,  and  note  its  position,  whether  or  not 
it  is  displaced,  whether  movable  or  fixed,  and  finally  the  size  and  con- 
sistency of  the  uterus.  Note  the  presence  or  absence  of  a  mass  in  the 
pouch  of  Douglas;  its  consistency,  fixation,  and  tenderness.  Palpate 
in  turn  each  tube  and  ovary  by  passing  the  vaginal  fingers  first  to  one 
side  and  then  to  the  other  side  of  the  cervix,  and  endeavor  to  locate 
and  outline,  between  these  and  the  fingers  of  the  abdominal  hand, 
the  uterine  adnexa.  No  matter  what  the  age,  social  condition,  or 
history  of  your  patient,  always  exclude  pregnancy  before  reaching  a 
final  diagnosis. 

Preparation  for  Operation  and  After-care. — Enough  has  been  said 
on  this  subject  in  Chapter  XXII  in  reference  to  abdominal  operations. 
But  a  few  words  are  necessary  in  regard  to  vaginal  operations.  It 
is  desirable  to  have  all  such  patients  in  bed,  and  to  have  the  parts 
thoroughly  cleansed  by  douching  twice  daily  for  several  days  before 
operation.  No  operation  should  be  done  while  the  parts  are  acutely 
inflamed,  nor  during  a  menstrual  period  unless  immediate  operation  is 
imperative.  The  bowels  should  be  thoroughly  opened  by  a  purge  given 
early  in  the  day  before  that  set  for  operation,  and  a  cleansing  enema 
should  be  given  at  least  six  hours  before  the  time  of  operation  (the 
previous  evening  if  necessary).  If  a  purge  is  not  given  until  the  night 
before  operation,  the  bowels  may  be  so  loose  as  to  move  during  the 
operation  and  soil  the  wound.  The  bladder  should  be  emptied  just 
before  the  operation.  When  the  patient  is  in  position  on  the  table 
the  vagina  is  thoroughly  washed  with  soap  and  hot  water,  wiped  out 
with  alcohol,  and  douched  with  bichloride  solution. 

After  operation  the  patient  should  remain  in  bed  for  at  least  two 
weeks,  often  longer.  The  bowels  should  not  be  locked  up  by  opiates, 
and  if  they  do  not  move  by  the  fourth  day  castor  oil  should  be  given; 
whenever  possible  an  enema  should  be  avoided.  The  urine  should 
not  be  drawn  by  catheter  unless  retention  occurs;  after  the  patient 
has  urinated  the  vulva  should  be  gently  douched  with  some  hot 
antiseptic  solution  and  gently  dried  and  powdered. 

Congenital  Malformations. — The  vulva  may  be  congenitally  imper- 
forate, but  the  condition  is  more  often  due  to  adhesion  of  the  labia 
minora  as  the  result  of  vulvitis  in  childhood  (Fig.  1089).  In  most  cases, 
whether  congenital  or  acquired,  the  occluding  membrane  is  very  thin, 


L126 


SURGERY  OF   THE  FEMALE  GENITALS 


and  is  readily  ruptured  by  pulling  the  labia  apart  or  by  rupturing 
adhesions  with  a  grooved  direetor;  occasionally  the  use  of  scalpel  or 
scissors  is  necessary.  Reunion  should  be  prevented  by  dressing  the 
raw  surfaces  with  boric  acid  ointment  and  the  daily  introduction 
of  a  fold  of  lint. 


Fig.  1089. — Adhesion  of  labia  from  vulvitis  in  infancy. 
Children's  Hospital. 


Age  three  years. 


Imperforate  Hymen. — Imperforate  hymen  seldom  is  recognized  until 
after  the  age  of  puberty,  when  the  non-appearance  of  the  menstrual 
flow,  and  its  ultimate  damming  up  in  the  vagina  (hematocolpos)  and 
in  the  uterus  (hematometra)  cause  a  local  examination  to  be  made. 
If  these  conditions  continue  unrelieved  for  several  years  a  large  pelvic 
tumor  may  develop,  and  some  danger  exists  of  peritonitis  from  rupture 
of  the  uterus  or  tubes  or  from  leakage  of  the  uterine  contents  through 
the  fimbriated  extremity  of  the  tubes.  Treatment  consists  in  incision 
through  the  hymen  and  drainage,  and  if  necessary  in  some  form  of 
plastic  operation  to  prevent  cicatricial  contraction. 

Absence  of  the  Vagina. — Absence  of  the  vagina  usually  is  a  congenital 
defect,  but  occasionally  the  vagina  becomes  obliterated  by  cicatricial 
contraction.  If  the  presence  of  a  uterus  and  adnexa  can  be  demon- 
strated (exploratory  laparotomy  may  be  necessary),  attempts  may  be 
made  to  construct  a  new  vagina.  Various  external  plastic  operations 
have  been  employed,  but  usually  without  permanent  success.  The 
plan  introduced  by  Baldwin  (1907)  though  the  mortality  is  higher, 
has  given  much  better  results:  a  loop  of  the  small  intestine  is  excluded 
from  the  intestinal  tract,  and  still  attached  to  its  mesentery  (which 
must  be  sufficiently  long)  is  sutured  in  place  between  bladder  and 
rectum,  opening  below  at  the  vulvar  orifice,  and  being  closed  above 
around  the  cervix  uteri.  The  continuity  of  the  intestinal  tract  is 
then  restored  by  end-to-end  or  lateral  anastomosis. 

Stenosis  of  the  Cervix. — Stenosis  of  the  cervix,  usually  from  congenital 
hypoplasia  and  accompanied  by  anteflexion  of  the  uterus,  is  a  frequent 
cause  of  dysmenorrhea  in  girls  and  young  women.     The  dysmenor- 


GONORRHEA  IN  THE  FEMALE 


1127 


rhea  is  of  the  obstructive  type,  that  is,  it  is  greatest  preceding  the  flow 
which  often  is  delayed  and  usually  is  scanty.  The  patient  usually  is 
sterile,  and  proper  treatment  often  is  followed  by  conception.  The  kink 
in  the  uterus  favors  retention  of  secretions,  and  causes  venous  conges- 
tion, with  resulting  endometritis.  Examination  shows  an  undersized 
but  lengthened  (conical)  cervix  with  pin-point  os,  firm  and  unyielding 
to  the  touch,  and  the  fundus  uteri  close  beneath  the  symphysis. 

Treatment. — Forcible  dilatation,  the  patient  being  anesthetized,  is 
seldom  productive  of  permanent  cure,  even  if  the  operation  is  many 
times  repeated.  It  is  better  to  incise  the  cervix  posteriorly  in  the 
mid-line  almost  up  to  the  internal  os  and  recto-uterine  fold  of  perito- 
neum; a  small  wedge  of  tissue  is  cut  out  on  each  side  (Fig.  1090),  and 
the  cut  surface  on  each  side  is  then  folded  on  itself  so  as  to  pull  the 
anterior  lip  of  the  cervix  backward  {Dudley's  operation,  1891).  If  the 
anterior  lip  is  very  long  it  may  be  excised.  Or  Pozzi's  operation  may  be 
done:  this  consists  in  dividing  the  cervix  bilaterally,  hollowing  out  and 
infolding  upon  itself  each  of  the  four  denuded  surfaces. 


Fig.  1090. — Dudley's  operation  for  anteflexion.    Patient  in  the  Sims  position.    (Findley. ) 


Malformations  of  the  Uterus. — Malformations  of  the  uterus  are  not 
very  rare.  Ectopic  pregnancy  may  occur  in  one  of  the  rudimentary 
horns  of  a  uterus  bicornis.  In  cases  of  double  uterus  (uterus 
didelphys)  it  is  best,  usually,  to  remove  one  uterus  by  hysterectomy, 
to  prevent  complications  during  a  possible  pregnancy. 

Gonorrhea  in  the  Female. — As  noted  at  p.  1128,  the  occurrence  of 
gonococcic  infection  of  the  genito-urinary  tract  in  the  female  often 
is  not  attended  by  very  acute  symptoms.  The  gonococci  are  deposited 
at  the  vulvar  orifice  or  in  the  vagina  by  mediate  or  immediate  con- 
tagion, and  within  a  few  days  may  produce  acute  urethritis,  vulvitis, 
and  vaginitis.  Frequently,  however,  no  acute  symptoms  develop, 
but  the  gonococci  lodge  and  proliferate  in  the  vulvo-vaginal  glands 
(Bartholinitis)   and  in  the  cervical  glands   (endo-cervicitis)   and  are 


1128  SURGERY  OF  THE  FEMALE  GENITALS 

exceedingly  difficult  to  dislodge.  When  the  disease  reaches  a  chronic 
stage,  it  persists  indefinitely,  causing  no  particular  disability  at  times, 
but  at  others  producing  local  and  distant  disturbances  which  render 
life  a  burden.  Moreover,  the  patient  is  a  constant  carrier  of  infection, 
and  this  may  be  conveyed  to  innocent  persons,  especially  children, 
by  mediate  contagion.  Recrudescences  of  the  infection  occur  from 
time  to  time,  and  with  each  new  attack  the  germs  travel  higher  in 
the  genital  tract,  spreading  from  the  cervix  to  the  uterus  (endometritis), 
where  the  infection  does  not  linger,  to  the  tubes,  ovaries,  and  peri- 
toneum; here  occur  acute  and  chronic  salpingitis,  pelvic  peritonitis, 
pyosalpinx,  tubo-ovarian  abscess,  etc.  These  complications  frequently  de- 
velop first  in  the  puerperium,  especially  after  miscarriages  or  abortions. 

Urethritis. — The  urethra  almost  always  is  affected  when  gonorrhea 
attacks  the  female,  but  the  course  of  the  disease  is  much  less  acute 
in  its  symptomatology,  and  residual  foci  of  infection  are  much  less 
frequent  than  in  the  male.  Occasionally  a  focus  of  infection  remains 
in  the  suburethral  glands  of  Skene,  but  abscess  formation  is  extremely 
rare.  These  abscesses  (one  in  each  gland)  protrude  just  below  the 
external  urinary  meatus,  and  pressure  on  them  will  make  pus  exude 
from  their  orifices  in  the  floor  of  the  urethra,  about  0.5  cm.  within 
the  meatus.  They  should  not  be  confused  with  urethral  caruncles, 
which  are  inflammatory  hypertrophies  or  angeiomatous  out-growths  of 
the  urethral  mucous  membrane,  protruding  from  the  urinary  meatus, 
not  beneath  it  through  the  anterior  vaginal  wall.  Some  caruncles 
bleed  or  are  excessively  painful;  such  should  be  excised,  with  a  wide 
area  of  the  mucosa  from  which  they  spring,  as  recurrence  is  frequent. 

Treatment. — The  treatment  of  gonococcic  urethritis  in  the  female 
is  subordinate  to  that  of  the  vulvitis  and  vaginitis  with  which  it  is 
accompanied. 

Vulvitis  and  Vaginitis. — These  are  exceedingly  common  in  infants 
and  little  girls,  usually  resulting  from  mediate  contagion  through  soiled 
towels,  etc.  In  them  the  symptoms  may  be  very  acute,  as  is  also  the 
case  in  the  young  nullipara,  but  in  the  case  of  women  who  have  borne 
many  children  the  vaginal  mucous  membrane  is  much  less  easily 
infected  and  gonococcic  vaginitis  is  rarely  seen.  The  patient  complains 
of  burning  pain,  worse  during  urination  and  defecation;  the  labia 
minora  are  red,  edematous,  and  tender;  there  is  a  profuse  purulent 
exudate,  in  which  gonococci  are  readily  found;  the  vaginal  walls  may 
be  fiery  red,  and  in  rare  instances  exfoliation  of  epithelium  and  ulcer- 
ation may  occur.  The  vulvo-vaginal  glands  of  Bartholin  are  exceed- 
ingly prone  to  harbor  the  infection  for  a  long  time,  and  abscess  forma- 
tion is  very  common  (Fig.  1091);  indeed  it  may  be  the  first  symptom 
to  bring  the  patient  to  a  physician.  The  vulvo-vaginal  abscess  points 
at  the  posterior  part  of  the  vulvar  opening,  between  the  labium  ma  jus 
and  minus,  and  is  to  be  treated  by  early  and  free  incision,  with  excision 
of  the  anterior  wall  of  the  abscess  sac,  or  if  possible  by  extirpation 
of  the  entire  gland,  as  recurrence  is  very  common  unless  radical 
treatment  is  adopted  at  the  first.     Occasionally  as  the  result  of  very 


VULVITIS  AND  VAGINITIS 


1129 


attenuated  infection,  or  from  cicatricial  closure  of  the  duct,  a  cyst  of 
Bartholin's  gland  develops  (Fig.  1092) ;  this  is  to  be  treated  by  excision. 
Treatment.— The  treatment  of  acute  gonococcic  vulvitis  and  vag- 
initis is  best  conducted  with  the  patient  in  bed,  until  the  most  acute 
symptoms  subside.  Great  care  must  be  taken  to  prevent  infection 
of  the  eyes,  as  well  as  conveyance  of  contagion  to  other  patients  by 
instruments,  dressings,  etc.  There  is  very  little  use  in  local  treatment, 
since  injections,  irrigations,  etc.,  are  very  apt  to  spread  the  infection 
further  up  the  genital  tract.  The  patient  should  be  confined  to  liquid 
diet  at  first,  especially  drinking  plenty  of  water;  urinary  antiseptics 
should  be  administered;  and  the  accumulation  and  crusting  of  the 
purulent  discharge  should  be  prevented  by  douching  the  vulva  fre- 
quently with  hot  permanganate  of  potash  solution,  or  some  other 
antiseptic.    The  heat  of  the  solution  is  beneficial  in  itself.    It  may  be 


Fig.  1091. — Abscess  of  the  vulvovaginal 
gland  of  Bartholin.  Duration  three 
days.  Acute  gonorrhea  in  a  patient  aged 
twenty-two  years.  Pennsylvania  Hos- 
pital. 


Fig.  1092. — Cyst  of  vulvo-vaginal  gland 
of  Bartholin.  Age  thirty-six  years ;  dura- 
tion fourteen  years.  Attached  by  two 
pedicles  to  right  labium  minus.  Episcopal 
Hospital. 


well  to  leave  a  rubber  tube  in  the  vagina,  to  promote  drainage.  As 
the  discharge  lessens  and  tenderness  becomes  less,  the  rubber  tube 
may  be  substituted  by  a  glycerin  tampon,  changed  daily.  When  the 
chronic  stage  is  reached  the  infection  probably  will  be  found  to  be 
localized  in  the  cervix  or  the  Fallopian  tubes;  the  local  treatment 
of  these  affections  is  discussed  below. 

Chronic  Gonococcic  Vaginitis,  especially  in  children,  is  most  success- 
fully combated  by  the  use  of  vaccines;  without  their  use  a  leucor- 
rheal  discharge  may  persist  indefinitely,  and  though  no  gonococci 
may  be  found  by  microscopical  examination  on  many  occasions,  any 
local  irritation  may  bring  them  from  their  hiding  places.  In  both 
children  and  adults  a  so-called  "cure"  of  the  disease  usually  means 
only  latency  of  symptoms.  Some  authorities  teach  that  a  woman 
once  infected  with  gonococci  is  always  infected. 

In  the  use  of  vaccines  for  chronic  gonococcic  vaginitis  in  children,  the 


1130  Sl'h'CKUY  OF   THE  FEMALE  GENITALS 

directions  of  B.  W.  Hamilton  (1910)  may  be  followed:  give  50,000,000 

killed  gonococci  by  hypodermic  injection  every  fifth  day,  increasing 
the  dose  by  10,000,000  until  five  injections  have  been  given,  the  last 
dose  being  90,000,000  gonococci.  After  a  ten-day  interval  repeat  the 
same  treatment  if  necessary.  In  recent  cases  Hamilton  found  that 
six  injections  usually  cured. 

Endocervicitis. — This  usually  is  gonorrheal  in  origin,  mixed  infec- 
tion occurring  subsequently  and  aggravating  the  condition.  The 
chief  symptom  is  a  leucorrheal  discharge,  thick  and  purulent.  Men- 
struation occurs  irregularly,  and  usually  the  flow  is  greater  than  normal. 
Examination  through  the  speculum  usually  reveals  a  plug  of  tenacious 
muco-pus  protruding  from  the  os.  Microscopically,  the  glands  which 
line  the  cervical  canal  are  seen  to  be  swollen  and  cystic,  and  much 
increase  in  the  stroma  may  occur,  leading  to  hypertrophy  or  elonga- 
tion of  the  cervix.  The  cervix  may  have  erosions  or  actual  ulcerations 
on  its  vaginal  surface. 

Treatment. — Treatment  by  palliative  means  (douches,  tampons, 
local  applications  or  argyrol,  iodin,  etc.)  rarely  is  efficient.  Even 
thorough  scraping  of  the  cervical  canal,  the  patient  being  anesthe- 
tized, generally  fails  to  effect  a  cure.  The  best  treatment  is  formal 
excision  of  the  diseased  tissue,  with  plastic  restoration  of  the  cervical 
canal:  the  cervix  is  split  bilaterally,  and  a  wedge  of  tissue  (including 
the  cervical  mucosa)  is  removed  from  each  lip;  then  the  cervical  flaps 
are  folded  upon  themselves  and  their  free  borders  sutured  to  the  mucosa 
at  the  internal  os  (Schroeder's  operation,  Figs.  1093  and  1094). 


Fig.    1093. — Schroeder's  operation:    the  Fig.  1094. — Schroeder's  operation:  the 

shaded  areas  are  excised.  flap3  are  sutured. 

Endometritis. — Endometritis  is  a  much  rarer  affection  than  com- 
monly believed.  Most  patients  said  to  have  endometritis  have  an 
entirely  different  lesion  as  the  main  cause  of  their  symptoms.  The 
symptoms  of  which  they  complain  are  painful,  prolonged  and  irregular 
menstruation,  leucorrheal  discharge  between  their  periods,  a  certain 
amount  of  backache,  etc.  Examination  shows  the  existence  of  endo- 
cervicitis, or  salpingitis,  or  both;  and  it  is  some  such  lesion,  and  not 
a  possibly  accompanying  but  relatively  insignificant  endometritis, 
which  is  responsible  for  the  symptoms.  Endometritis  which  exists 
as  the  most  important  lesion  usually  results  from  infection  following 


ENDOMETRITIS 


1131 


abortion,  miscarriage,  or  labor.  Occasionally  the  disease  occurs  in 
the  nullipara  or  in  the  aged;  in  these  instances  it  usually  is  caused  by 
stenosis  of  the  os,  or  displacements  of  the  uterus  which  cause  conges- 
tion or  interfere  with  proper  drainage.  If  the  disease  continues  long 
untreated,  the  entire  uterine  body  may  become  affected  (metritis). 
The  diagnosis  of  endometritis,  except  in  the  rare  virginal  and  senile 
forms,  depends  upon  the  recognition  of  the  symptoms  mentioned  above 
occurring  after  a  miscarriage  or  a  prolonged  convalescence  from 
labor. 


Fig.  1095. — Curettage  of  the  uterus.     (Findley.) 


Treatment. — Much  can  be  done  to  prevent  the  development  of 
endometritis  by  avoiding  infection  in  the  puerperium,  but  when  the 
disease  is  fully  established,  treatment  is  not  very  satisfactory.  The 
first  essential  is  to  secure  free  drainage,  by  dilatation  of  the  os,  main- 
tained by  introduction  of  a  glass  drainage  tube  (Wy lie's  drain);  the 
hypertrophied  and  diseased  endometrium  should  be  removed  at  the 
same  time  by  the  dull  curette  (Fig.  1095),  but  this  step  is  quite  useless 
unless  free  drainage  is  provided  after  the  operation.  The  tube  should 
be  retained  for  several  weeks,  and  may  be  replaced  later  if  necessary. 
If  other  lesions  (endocervicitis,  salpingitis)  exist  they  should  receive 
appropriate  treatment. 

Acute  Metritis. — Acute  metritis  is  seldom  seen  except  in  cases  of 
puerperal  sepsis  (p.  1150). 


1132  SURGERY  OF   THE  FEMALE  GENITALS 

Chronic  Metritis.— Chronic  metritis,  as  noted  above,  usually  is  a 
sequel  of  neglected  cases  of  endometritis.  At  first  the  uterus  is  large, 
soft  and  boggy,  but  later  becomes  sclerosed,  though  usually  retaining 
some  enlargement.  Hyaline  degeneration  is  not  infrequent,  and  malig- 
nant changes  may  occur.  The  symptoms  resemble  those  of  chronic 
endometritis,  but  usually  are  more  severe  and  often  are  accompanied 
by  pseudo-hysterical  phenomena.  Menorrhagia  is  excessive,  and  the 
patients  become  chronic  invalids.  The  diagnosis  from  small  intersti- 
tial or  submucous  fibroids  may  be  difficult.  The  only  efficient  treat- 
ment is  hysterectomy.  The  condition  is  no  more  curable  by  medicine 
or  palliative  local  treatment  than  sclerosis  of  any  other  organ. 

Salpingitis. — Inflammation  of  the  Fallopian  tubes  usually  is  due 
to  the  local  action  of  gonococci,  the  infection  travelling  upward  by 
gradual  steps  from  its  resting  places  in  the  vulva  and  cervix.  Tuber- 
culosis of  the  Fallopian  tubes  has  been  mentioned  in  Chapter  XXII. 

Acute  Salpingitis. — Acute  salpingitis  is  most  frequent  in  nulliparae; 
it  may  occur  during  an  acute  attack  of  gonorrhea  (vulvo-vaginitis  and 
urethritis)  or  may  arise  later  as  the  result  of  some  factor  which  lessens 
the  resistance  of  the  pelvic  organs.  There  is  always  a  certain  amount 
of  peri-salpingitis  (pelvic  peritonitis)  accompanying  acute  inflammation 
of  the  tubes,  and  pathologically  the  condition  is  not  unlike  an  attack  of 
appendicitis,  except  that  the  infecting  organism  is  the  gonococcus  and 
not  the  more  deadly  streptococcus  or  colon  bacillus.  The  symptoms 
are  those  of  peritonitis  localized  to  the  pelvic  region,  usually  more 
marked  on  one  side  than  on  the  other,  and  not  attended  by  notable 
gastro-intestinal  symptoms.  The  tenderness  is  close  to  Poupart's 
ligament,  too  low  and  too  near  the  median  line  for  typical  appendicitis; 
and  the  history  of  the  case  and  vaginal  examination  almost  always 
indicate  the  true  condition. 

Treatment. — Keep  the  patient  in  bed,  and  treat  her  as  for  diffuse 
peritonitis  (p.  862);  there  is  no  fear  of  gangrene  or  perforation  of  the 
tube,  as  there  is  when  the  appendix  is  acutely  inflamed ;  and  the  acute 
attack  subsides  almost  invariably  within  a  few  days.  The  exceptions 
are  a  few  cases  of  salpingitis  of  puerperal  origin;  but  most  of  these, 
even,  subside  under  proper  conservative  treatment.  The  mortality 
following  early  operation  is  high;  but  if  recurrent  attacks  of  pelvic 
peritonitis  occur  in  spite  of  conservative  treatment  it  may  become 
necessary  to  operate  before  the  chronic  stage  has  been  reached.  The 
operation  consists  in  removal  of  the  affected  tube  (salpingectomy, 
p.  1137)  and  of  the  ovary  also  if  this  is  involved.  But  whenever 
possible  no  operation  should  be  done  for  several  months  after  the 
subsidence  of  an  acute  attack;  after  such  an  interval  the  virulence  of 
the  microbes  is  very  much  attenuated,  and  often  the  pus  in  the  tube 
is  found  to  be  sterile. 

Chronic  Salpingitis. — Chronic  salpingitis  is  a  term  used  to  describe 
a  condition  which  is  not  so  much  a  chronic  inflammation  of  the  tubes, 
as  it  is  the  result  of  a  previous  acute  inflammation.  The  tubes  and 
ovaries   are   bound   down  in   adhesions,  often  involving   omentum, 


PYOSALPINX  OR   PUS-TUBE 


1133 


sigmoid,  cecum  and  appendix,  and  less  often  the  pelvic  coils  of  small 
intestine.  There  is  difficulty,  and  often  pain,  in  securing  evacuation 
of  the  bowels;  an  aching  sensation,  or  dragging  pain,  is  nearly  constant 
in  the  lateral  pelvic  regions,  especially  when  the  patient  is  on  her  feet; 
referred  pains  (small  of  back,  thighs,  groins)  are  frequently  present; 
there  usually  is  leucorrhea,  with  painful,  profuse,  and  irregular  men- 
struation, and  the  woman  becomes  a  chronic  invalid.  Examination 
shows  the  uterus  and  adnexa  more  or  less  fixed  by  adhesions;  con- 
siderable tenderness  is  present;  and  the  pelvic  organs  cannot  be 
clearly  outlined. 

Treatment  consists  in  removal  of  the  focus  or  rather  foci  of  infection 
(salpingo-oophorectomy),  releasing  the  adhesions,  and  covering  denuded 
peritoneal  surfaces  by  infolding  or  by  omental  grafts.  The  appendix 
usuallv  should  be  removed  also. 


Fig.  1096.- 


-Right  pyosalpinx,  seen  from  posterior  aspect.     The  tube  is  distended, 
pouched,  and  surrounds  the  ovary.     Episcopal  Hospital. 


Pyosalpinx,  or  Pus-tube,  results  from  accumulation  of  the  products 
of  inflammation  within  the  lumen  of  the  Fallopian  tube,  owing  to 
inflammatory  occlusion  of  the  fimbriated  and  uterine  extremities 
(Fig.  109(3).  The  exciting  cause  almost  always  is  the  gonococcus,  and 
the  condition  usually  is  a  remote  sequel  of  acute  salpingitis.  It  has 
been  noted  already  that  gonococcic  infection  of  the  tubes  becomes 
attenuated  soon,  and  that  after  several  months  the  contents  usually 
are  sterile.  A  patient  with  pus-tubes  (both  sides  usually  are  diseased) 
as  a  rule  gives  a  history  of  having  passed  through  several  attacks  of 
pelvic  peritonitis;  and  in  many  cases  a  distinct  history  of  the  primary 
infection  can  be  secured.  A  pus-tube  often  follows  the  first  childbirth 
in  cases  where  the  patient  has  been  inoculated  with  not  very  virulent 
gonococci;  thereafter  the  woman  usually  is  sterile.  If  the  pus-tube 
in  such  a  woman  first  begins  to  cause  symptoms  a  number  of  years 
after  the  last  childbirth,  it  may  be  mistaken  for  a  case  of  ectopic 
gestation  (p.  1147).  Frequently  pus-tubes  exist  for  years  without 
causing  notable  symptoms;  but  in  most  cases  there  is  an  annoying 
leucorrhea,  and  the  patient  may  be  completely  disabled  by  painful 


1134  SURGERY  OF   THE  FEMALE  GENITALS 

adhesions  to  the  intestinal  tract,  by  recurrent  attacks  of  pelvic  peri- 
tonitis from  leakage  of  the  contents  of  the  sac,  etc.  On  examination 
it  is  usual  to  find  the  cervix  displaced,  and  a  mass  in  the  recto-uterine 
pouch,  sometimes  clearly  demonstrable  as  springing  from  one  side  or 
other  of  the  uterus;  a  similar  but  smaller  mass,  not  large  enough  to 
occupy  the  pouch  of  Douglas,  may  be  present  on  the  other  side  of  the 
uterus.  Pus-tubes  usually  are  fixed  by  adhesions,  but  they  may  be 
very  movable,  and  their  existence  should  not  be  ruled  out  on  the 
ground  of  mobility  alone.  A  low,  immobile  mass,  especially  if  it 
results  from  puerperal  infection,  almost  always  is  a  pelvic  abscess; 
pus-tubes  form  a  high,  not  a  low  mass. 

Treatment.  —  If  symptoms  are  present  the  diseased  structures 
should  be  removed.  If  the  woman  is  young  and  the  ovary  healthy, 
it  should  be  left,  only  the  tube  being  removed,  but  in  many  cases 
the  ovary  is  degenerated  ("cystic  degeneration"  from  chronic  oophor- 
itis, p.  1 135)  and  will  prove  useless  or  even  harmful  if  preserved.  The 
entire  tube  should  be  removed,  excising  its  interstitial  part  from  the 
uterine  cornu;  in  some  cases,  in  addition  to  the  removal  of  both  tubes 
and  ovaries  it  is  necessary  to  remove  the  uterus  also,  either  to  facili- 
tate the  operation,  or  because  this  organ  itself  is  diseased  (chronic 
metritis).  The  operation  of  salpingo-oophorectomy  is  described  at 
p.  1136.  If  the  woman  complains  of  no  particular  symptoms,  it  often 
is  best  to  do  no  operation.  I  have  known  a  woman  with  an  undeniable 
pus-tube  pass  through  a  normal  pregnancy  and  puerperium  and  give 
birth  to  a  healthy  child. 

Rupture  of  a  pus-tube  is  rare  while  its  contents  are  still  highly  infec- 
tious; when  it  occurs,  it  is  followed  by  diffuse  peritonitis,  which  is  best 
treated  not  by  immediate  operation,  but  by  strict  adherence  to  the 
rules  laid  down  in  Chapter  XXII  for  the  non-operative  treatment  of 
diffuse  peritonitis.  Immediate  operation  has  a  very  high  mortality, 
but  if  the  patient  is  treated  expectantly  the  infection  almost  always 
becomes  localized  again,  frequently  in  the  form  of  a  pelvic  abscess. 

Tubo-ovarian  Abscesses. — This  is  an  abscess  which  involves  both 
tube  and  ovary  (Fig.  1097).  Usually  the  primary  condition  is  that  of 
pyosalpinx,  and  the  ovary  becomes  invaded  by  direct  extension.  It 
is  rare  for  an  ovarian  abscess  to  exist  alone,  or  for  it  to  spread  to  the 
tube  secondarily.  But  when  a  small  ovarian  cyst  or  corpus  luteum 
bursts  into  an  adherent  pus-tube,  infection  of  the  whole  ovary  may 
result,  the  tube  and  ovary  then  forming  one  mass.  Sometimes  tube 
and  ovary  are  in  communication  only  through  an  intervening  pelvic 
abscess.  It  is  difficult  to  distinguish  a  tubo-ovarian  abscess  from  an 
ordinary  pus-tube  before  operation,  as  the  symptoms  and  physical 
signs  are  almost  identical. 

Treatment  is  the  same  as  for  pyosalpinx. 

Hydrosalpinx. — Hydrosalpinx,  or  a  collection  of  serous  fluid  in  the 
tube,  sometimes  develops  as  a  terminal  stage  of  pyosalpinx;  often, 
however,  the  collection  of  fluid  appears  to  have  been  serous  from  the 
beginning.     Hydrosalpinx  frequently  develops  on  one  or  both  sides 


OOPHORITIS  OR  OVARITIS 


1135 


in  cases  of  uterine  fibroids.      Treatment  is  that  of  the  complicating 
condition. 


Fig.  1097. — Left  tubo-ovarian  abscess,  seen  from  posterior  aspect.     Ruptured  before 
operation,  causing  fatal  peritonitis  (colon  bacillus).     Episcopal  Hospital. 

Oophoritis  or  Ovaritis  is  much  less  frequent  and  produces  much 
less  conspicuous  symptoms  than  salpingitis.  Like  the  latter  condition, 
of  which  it  is  almost  always  a  direct  sequel,  it  may  be  acute  or  chronic. 
The  symptoms  cannot  well  be  differentiated  from  those  of  the  compli- 
cating salpingitis.  In  acute  vvaritis  the  ovary  is  swollen,  tender,  and 
often  prolapsed  into  Douglas's  pouch;  abscess  of  the  ovary  is  rare  unless 
it  is  the  result  of  secondary  infection  of  a  preexistent  ovarian  cyst,  or 
occurs  in  the  form  of  a  tubo-ovarian  abscess,  already  described. 


Fig.  1098. — Microcystic  degeneration  of  the  ovary;  the  ovary  to  the  right  shows 
numerous  small  cysts  scattered  over  the  surface;  these  are  Graafian  follicles  which 
have  undergone  cystic  degeneration,  and  which  it  is  said  may  take  on  excessive  growth 
and  develop  into  large  tumors,  or  may  remain  as  here  represented;  on  the  other  side 
is  shown  a  similar  condition  of  the  ovary  in  section.     (Dudley.) 

Treatment. — In  acute  ovaritis  the  treatment  should  be  the  same  as  in 
cases  of  acute  salpingitis.  If  suppuration  occurs,  the  proper  treat- 
ment is  oophorectomy.  In  chronic  ovaritis  the  ovary  is  the  seat  of 
"cystic  degeneration,"  and  should  be  removed  along  with  the  tube 
if  this  is  diseased  (Fig.  1098);  since  both  ovaries  usually  are  affected, 


1 130 


SURGERY  OF   THE  FEMALE  GENITALS 


it  is  well,  if  the  patient  is  a  young  woman,  and  a  portion  of  the  ovary 
remains  healthy,  to  leave  it  as  a  transplant  in  the  abdominal  wound; 
there  are  fair  prospects  that  it  will  possess  sufficient  function  to 
prevent  or  delay  an  artificial  menopause. 

Salpingo-obphorectomy. — The  abdomen  is  opened  by  a  paramedian 
incision  about  10  to  15  cm.  long,  above  the  pubes.  In  any  case  in 
which  there  is  any  possibility  of  pus  being  present,  the  surgeon  should 
wall  off  the  small  intestines  with  gauze  packs  as  soon  as  the  peri- 
toneum is  opened,  and  before  the  pelvis  is  explored.  Place  the  first 
gauze  pack  on  the  right  or  left  side  of  the  pelvic  cavity,  not  in  the 


'A         'V  '//         Y. 

P.  « 


Fig.  1099. — Isolating  the  pelvic  cavity  by  the  use  of  gauze  packs.     (See  Fig.  896.) 

(Dudley.) 

mid-line;  if  the  first  pack  is  inserted  in  the  mid-line  the  intestines  will 
prolapse  into  the  pelvis  on  both  sides  of  it,  and  it  will  be  more  difficult 
to  control  them.  The  second  gauze  pack  is  placed  in  the  mid-line, 
and  the  third  on  the  left,  thus  pushing  the  troublesome  small  intestines 
completely  out  of  harm's  way  (Fig.  1099).  If  it  is  known  to  be  a  clean 
case  it  will  facilitate  these  manoeuvres  to  place  the  patient  in  the  Tren- 
delenburg (high  pelvic)  position  as  soon  as  the  abdomen  has  been 
opened;  but  if  there  is  any  danger  of  infection,  it  is  safer  to  isolate 
the  general  peritoneal  cavity  by  gauze  while  the  patient's  body  is 
still  horizontal,  and  then  to  raise  it  into  the  Trendelenburg  position. 


SALPINGO-OOPHORECTOM  Y 


1137 


If  many  adhesions  are  present  it  may  be  difficult  at  first  to  recog- 
nize anatomical  landmarks.  First  locate  the  fundus  of  the  uterus. 
Sometimes  it  is  covered  by  omentum  or  sigmoid.  Then  cautiously 
and  gently  work  your  fingers  down  behind  it  until  Douglas's  cul-de-sac 
is  reached.  Then  endeavor  to  isolate  the  tubes  and  ovaries  by  blunt 
dissection  with  the  fingers,  working  from  the  mid-line  outward  and 
pushing  the  omentum  and  intestine  away  from  the  pelvic  organs 
rather  than  enucleating  the  latter  from  the  intestines.  It  is  not  very 
difficult  to  tear  a  hole  in  the  intestines  if  undue  haste  or  force  is  em- 
ployed. From  time  to  time  mop  up  the  clotted  blood  which  collects 
in  the  pelvis  as  the  result  of  rupture  of  adhesions.  When  at  last  the 
posterior  surfaces  of  the  broad  ligaments  are  outlined,  turn  your  atten- 
tion to  their  anterior  surfaces,  beginning  at  the  fundus  of  the  uterus 
again,  where  the  attachments  of  the  tube  and  of  the  round  ligament 
form  valuable  landmarks,  and  then  work  out  toward  the  sides  of 
the  pelvis. 


Fig.  1100. — Sulpingo-oophorectomy:  on  the  right  the  suturing  has  been  completed; 
on  the  left  the  method  of  resecting  the  uterine  cornu  is  indicated.     (Dudlc.\ .  I 


If  few  or  no  adhesions  are  present,  the  tube  and  ovary  from  each 
side  can  be  brought  into  the  wound  without  difficulty.  If  the  tube 
only  is  diseased,  it  alone  should  be  removed  (salpingectomy);  or  if 
the  tube  is  healthy  and  the  ovary  diseased,  oophorectomy  should  be 
done.  In  most  cases  both  tube  and  ovary  are  removed  together. 
The  blood  supply  is  readily  controlled  by  a  ligature  around  the  ovarian 
artery,  at  the  lateral  margin  of  the  broad  ligament,  and  another  close 


1138  SURGERY  OF   THE  FEMALE  GENITALS 

to  the  uterus,  just  below  the  tube,  where  the  uterine  and  ovarian 
arteries  anastomose.  The  tube  and  ovary  are  then  cut  free  from  the 
broad  ligament  and  any  oozing  points  temporarily  clamped  in  hemo- 
stats.  The  tube  should  be  removed  by  resecting  a  wedge-shaped  piece 
of  the  uterine  cornu,  unless  the  uterine  tissue  is  very  friable,  and  will 
not  hold  sutures,  when  it  is  sufficient  to  ligate  the  uterine  stump  of 
the  tube.  The  cut  edges  of  the  broad  ligament  are  then  sutured  by  a 
lock  stitch  of  chromic  catgut,  controlling  any  venous  oozing  (Fig. 
1 100).  The  ends  of  the  ligatures  on  the  ovarian,  and  uterine  arteries 
are  then  tied  together,  thus  shortening  the  broad  ligament,  and  retain- 
ing the  fundus  in  proper  position.  Usually  it  is  well  to  invert  the  edges 
of  the  broad  ligament  by  another  row  of  sero-serous  sutures,  burying 
the  first  row  and  covering  the  uterine  stump  of  the  tube.  This  lessens 
the  chance  of  post-operative  adhesions. 

In  some  cases  it  is  safer  to  leave  a  tube  or  gauze  to  drain  the  floor 
of  the  pelvis,  but  where  there  has  not  been  much  soiling  of  the  pelvic 
structures,  and  no  oozing  persists,  the  abdominal  wound  may  be 
closed  without  drainage. 

Birth  Injuries. — Lacerations  of  the  cervix  and  perineum  are  the 
most  frequent  obstetrical  injuries,  and  often  produce  such  distressing 
symptoms  as  to  demand  operative  relief. 

Lacerations  of  the  Cervix  may  be  unilateral  or  bilateral;  anterior  or 
posterior  lacerations  are  rare,  as  are  stellate  lacerations.  When  these 
patients  reach  the  surgeon  healing  has  occurred,  but  it  is  healing  with 
deformity:  the  cervical  mucosa  becomes  everted,  and  resembles  an 
ulcerated  surface;  erosions  frequently  form  on  the  vaginal  portion  of 
the  cervix,  and  annoying  leucorrhea  frequently  is  present.  If  the 
lacerations  are  very  wide  and  deep,  subsequent  pregnancies  may  ter- 
minate in  miscarriages  from  very  slight  provocation,  or  conception 
may  not  occur  at  all.  Moreover,  carcinoma  of  the  cervix  seldom 
occurs  except  in  the  scar  of  an  old  laceration;  and  this  is  the  chief 
argument  in  favor  of  habitual  operative  treatment.  But  before  any 
operation  is  done  for  laceration  of  the  cervix,  it  is  important  to  remedy 
inflammatory  conditions  in  the  uterus  and  adnexa,  since  the  inter- 
ference with  free  drainage  which  may  result  from  repair  of  a  cervical 
tear  may  cause  retention  of  uterine  secretions,  thus  aggravating  a 
chronic  endometritis  and  perhaps  indirectly  leading  to  the  develop- 
ment of  salpingitis.  At  the  time  of  operation  the  uterine  cavity 
should  be  cleansed  by  the  curette,  and  immediately  after  repair 
of  the  cervix  the  tubal  lesion,  if  any  exists,  should  be  treated  by 
laparotomy. 

Treatment. — The  operation  for  the  repair  of  a  lacerated  cervix  is 
known  as  trachelorrhaphy  ("tracheloplasty,"  Emmett,  1869).  It  con- 
sists in  denuding  the  torn  surfaces,  excising  the  cicatricial  tissue,  and 
restoring  the  cervix  to  normal  shape  by  sutures.  The  technique  is 
sufficiently  indicated  in  the  accompanying  illustration  (Fig.  1001).  In 
some  cases  where  the  lacerations  are  very  extensive,  or  the  cervix 


BIRTH  INJURIES 


1139 


hypertrophied,   amputation   of   the    cervix   is   required.      Schroeder's 
method  has  already  been  illustrated  (Figs.  1093  and  1094). 

Lacerations  of  the  Perineum  and  Pelvic  Floor  usually  produce  more 
discomfort  than  lacerations  of  the  cervix.  The  levator  ani  muscles 
are  composed  typically  of  three  portions :  a  posterior  portion,  entirely 
beneath  the  rectum,  which  is 
not' of  importance  in  the  pres- 
ent connection;  a  middle  por- 
tion, which  is  closely  applied 
to  the  sides  of  the  rectum; 
and  an  anterior  portion, 
which  meets  with  the  corre- 
sponding fibers  from  the  op- 
posite side,  at  the  perineal 
center.  In  superficial  tears 
little  more  is  torn  than  the 
juncture  of  these  anterior 
fibers,  and  some  of  the  fibers 
of  the  transversus  perinei,  at 
the  perineal  center.  In  com- 
plete tears  the  rupture  extends 
down  through  the  perineal 
center  and  involves  the  sphinc- 
ter ani  (Fig.  1102),  almost  al- 
ways entailing  fecal  incontin- 
ence. Neither  a  superficial  nor 
a  complete  tear  of  the  perineum 
necessarily  involves  the  pelvic 
floor  proper,  so  there  is  not 
much  loss  of  support  to  the 
pelvic  organs;  it  is  only  when 
the  tear  extends  up  one  or 
both  lateral  sulci  of  the 
vagina,  rupturing  the  middle  fibers  of  the  levator  ani  and  detaching 
them  from  the  sides  of  the  rectum  that  there  develops  a  tendency 
to  hernia  of  the  pelvic  contents  through  the  vulvar  orifice. 

The  symptoms  due  to  this  loss  of  support  in  the  pelvic  floor  are 
chiefly  a  feeling  of  weakness  in  the  pelvis  when  the  patient  stands  or 
walks;  and  dragging  sensations  in  the  lower  abdomen,  with  pains 
referred  oftenest  to  the  ovarian  or  lumbar  regions.  In  typical  cases 
the  vulvar  orifice  gapes,  the  anus  falls  backward  toward  the  coccyx, 
and  descends  to  a  lower  plane,  no  longer  being  placed  in  a  well  marked 
cleft  between  the  nates.  In  many  cases  the  anterior  wall  of  the  rectum 
protrudes  beneath  the  posterior  vaginal  wall,  forming  a  rectocele  (Fig. 
1103);  and  in  connection  with  this  there  often  develops  an  anterior 
colpocele  or  a  cystocele  (p.  1145).  If  the  condition  is  neglected  it  fre- 
quently leads  to  prolapse  or  to  procidentia  of  the  uterus. 


Fig.  1101.— -Trachelorrhaphy:  after  excision 
of  the  cicatricial  tissue,  sutures  of  No.  2  chromic 
catgut  are  passed,  beginning  at  the  apex. 
(Findley.) 


1140 


SURGERY  OF   THE  FEMALE  GENITALS 


Treatment. — The  operation  for  the  repair  of  a  lacerated  perineum 
is  known  as  perineorrhaphy.'      Its  nature  and  extent  depend  on  the 

character  of  the  tear.  If  both  lateral 
sulci  of  the  vagina  are  involved,  the 
best  operation  is  of  the  type  de- 
vised by  Emmett  (1883):  this  con- 
sists in  denuding  the  relaxed  areas, 
reuniting  the  levatores  ani  muscles 
to  the  lateral  rectal  and  posterior 
vaginal  walls,  and  restoring  the 
external  perineum  by  transverse 
sutures,  known  as  "crown  sut- 
ures." The  manner  in  which  the 
denudation  is  accomplished  is  of 
little  moment;  many  surgeons 
follow  Emmett  in  employing  scis- 
sors. Personally,  I  prefer  the 
scalpel,  and  I  am  in  the  habit  of 
proceeding  as  follows: 

1.    Dmvdation. — A  tenaculum  is 

placed    at    the    lowest   myrtiform 

caruncle  on  each   side,  and   these 

points  are  well  retracted  exposing 

the  rectocele.    A  point  on  this  is  selected,  which  when  drawm  forward 

by  tenaculum  will  reach  almost  but  not  quite  to  the  urinary  meatus 


Fig.  1102.  —  Complete  Laceration  of 
perineum.  Note  the  gaping  vulva,  and 
the  absence  of  the  anal  corrugations 
anteriorly.  No  rectocele.  Episcopal 
1 1<    pital. 


Fig.  1103. — Rectocele  and  cystocele.     P 


Hospital. 


1  It  was  Parvin's  teaching  that  the  terms  trachelorrhaphy  and  perineorrhaphy 
should  be  limited  to  immediate  repair  of  birth  injuries;  and  that  the  operations 
when  done  at  later  periods  should  be  called  tracheloplasty  and  perineoplasty.  The 
usual  operation  for  repair  of  a  lacerated  perineum  involves  also  the  vagina,  whence 
the  term  posterior  colporrhaphy  or  colpo-perineorrhaphy. 


PERINEORRHA  PHY 


1141 


(Fig.  1104).     When  these  three  tenacula  are  plaeed  in  apposition  the 
normal  form  of  the  vulvar  opening  is  restored.     A  fourth  tenaculum 


Fig.  1104. — Typical  incomplete  lacer- 
ation of  the  perineum.  The  tenaculum 
hooked  into  the  crest  of  the  rectocele  at 
point  b  draws  it  slightly  forward.  The 
other  two  tenacula  are  hooked  into  the 
lowest  remains  of  the  hymen,  points  d 
and  e  (carunculse  myrtiformes).  The  three 
tenacula  if  approximated  would  bring  into 
coincidence  points  h,  d,  and  e,  and  would 
show  what  surfaces  should  be  united. 
(Dudley.) 

is  then  placed  in  the  mid-line  at 
the  mucocutaneous  juncture. 
Point  b  (Fig.  1104)  is  then  drawn 
upward  and  point  /  downward, 
making  the  line  b  /  taut.  The* 
vaginal  mucosa  is  incised  from  b 
to/,  and  the  mucocutaneous  border 
from  /  to  e  and  from  /  to  d.  The 
flap  b  /  e  is  then  dissected  up  with 
scalpel  until  c,  the  apex  of  the 
lateral  vaginal  sulcus,  is  reached; 
this  point  becomes  apparent  when 
the  points  b  and  e  are  drawn  widely 
apart,  forming  the  lines  b  c  and  e  c 
(Fig.  1105).  When  the  dissection 
has  been  carried  as  high  as  these 
lines,  the  flap  of  mucous  membrane 
is  cut  free  by  dividing  it  along  e  c 
and  b  c  with  straight  scissors.  The 
same   procedure    is    then  carried 


Fig.  1105.— Same  as  1010.  Tenacu- 
lum at  d  removed  and  placed  at  /. 
Tenacula  b,  e,  and  /  make  traction  so 
as  to  render  tense,  lift  up  and  expose 
for  denudation  the  torn  sulcus  of  the 
left  side.  The  ridges  formed  by  the 
structures  drawn  taut  indicate  the  out- 
line of  the  surface  to  be  denuded. 
(Dudley.) 


Fig.  1106. — This  shows  the  surfaces 
denuded  and  ready  for  suturing.  It  is 
desirable  to  denude  on  each  side  some- 
what further  back  into  the  sulcus  than 
is  here  shown.     (Dudley.) 


I  I  !_' 


sriiCKHY    OF    THE    FEMALE   (1ENITALS 


out  on  the  patient's  right  side,  until  the  lines  <l  a  and  b  a  are  reached, 
when  the  flap  is  cut  free  by  scissors  passed  along  these  lines.  The 
denuded  surfaces  now  have  the  appearance  represented  in  Fig.  1 106. 


Fig.  1107. — Perineorrhaphy:    method  of  passing  sutures  in  one  of  the  lateral  sulci. 


2.  Suture. — The  method  of  inserting  the  sutures  is  important:  in  a 
typical  Emmett  operation  the  lateral  vaginal  sulci  are  sutured  first, 
beginning  at  the  apex  of  the  denuded  area  and  working  toward  the 

vaginal  outlet  (Fig.  1107).  Finally 
the  crown  sutures,  usually  of  silk- 
worm gut,  are  passed  from  the 
skin  surface  deeply  into  the  tissues 
of  the  perineum  from  one  side 
to  the  other,  uniting  the  levatores 
ani  in  the  median  line.  Dudley 
modifies  this  method  by  making 
separate  suture  of  the  levatores 
ani  with  buried  sutures  and  then 
closing  the  vaginal  sulci  (Fig. 
1108).  Finally  the  skin  of  the 
perineum  is  closed. 

In  cases  where  the  chief  damage 

is  at  the  vulvar  outlet,  it  is  sufficient 

to  suture  the  levatores  ani  alone. 

They  are  easily  exposed  through 

an  incision  about  5  to  8  cm.   in 

length  along  the  mucocutaneous 

border,  from  the  lowest  myrtiform 

caruncle  on  one  side  to  that  on 

the  other.     The  vaginal  mucous 

membrane  is  then  raised  by  blunt 

dissection,  the  levator  ani  on  each 

side  is  identified  and  drawn  into 

the  wound  with  forceps,  and  is  united  to  its  fellow  of  the  opposite 

side  by  buried  mattress  sutures  of  chromic  gut.     The  skin  incision  is 

then  closed. 


Fig.  1108. — All  the  sutures  in  the  two 
lateral  sulci  have  been  introduced  and 
tied.  The  levatores  ani  have  been  united 
in  the  median  line  by  buried  sutures. 
The  crown  suture,  which  brings  together 
the  two  carunculffi  myrtiformes  and  the 
posterior  vaginal  wall,  is  being  tied. 
This  completes  the  intravaginal  part  of 
the  operation.     (Dudley.) 


DISPLACEMENT  OF  THE  UTERUS  1143 

In  cases  of  complete  laceration  of  the  perineum,  it  is  necessary,  in 
addition  to  the  other  operative  procedures  indicated,  also  to  reunite 
the  retracted  ends  of  the  ruptured  sphincter  ani;  these  should  be 
exposed  through  a  transverse  or  inverted  V-shaped  incision  in  front 
of  the  anus,  should  be  accurately  identified,  and  sutured  to  each  other 
by  buried  sutures.  The  retracted  ends  of  the  ruptured  sphincter 
produce  dimples  in  the  skin  of  the  anus,  and  the  skin  between  the 
retracted  ends  is  not  puckered  as  is  the  rest  of  the  skin  surrounding 
the  anus  (Fig.  1102).  When  these  retracted  ends  have  been  sutured 
to  each  other  the  skin  is  puckered  normally  around  the  whole  circum- 
ference of  the  anus. 

Displacements  of  the  Uterus.— Anterior  Displacement.—  Anteflexion, 
involving  a  bend  in  the  axis  of  the  uterine  canal,  frequently  accom- 
panies stenosis  of  the  cervix,  and  requires  the  same  treatment  (p.  1126). 
In  anteversion,  which  is  rarer  than  anteflexion,  the  cervix  is  displaced 
backward,  there  being  no  abnormal  bend  in  the  axis  of  the  uterine 
canal.  Usually  the  displacement  is  caused  by,  or  at  least  is  asso- 
ciated with,  pelvic  inflammatory  disease,  and  is  relieved  by  proper 
treatment  of  the  complicating  condition. 

Posterior  Displacement  is  common;  and  here  also  retroflexion  is  more 
usual  than  retroversion.  In  extreme  degrees  the  fundus  occupies  the 
pouch  of  Douglas.  If  the  displacement  follows  pelvic  inflammatory 
disease  the  uterus  may  be  fixed  in  its  malposition  by  adhesions,  and 
may  cause  much  discomfort.  In  cases  due  to  relaxation  of  the  pelvic 
floor,  following  pregnancy,  no  noteworthy  symptoms  may  be  caused 
unless  relaxation  is  so  extreme  as  to  permit  prolapse  of  the  uterus, 
with  its  complicating  lesions. 

Treatment. — In  many  cases  following  pregnancy  (subinvolution  of  the 
uterus),  unattended  by  complicating  lesions,  and  causing  no  severe 
symptoms,  permanent  restoration  of  the  uterus  to  its  normal  position 
may  be  secured  by  mechanical  treatment.  The  fundus  should  be 
replaced  manually  by  the  surgeon  several  times  weekly,  and  its  reten- 
tion in  normal  position  favored  by  inserting  a  tampon  behind  the 
cervix  after  the  fundus  has  been  brought  forward.  Sometimes  a 
pessary  is  employed  for  this  purpose.  The  woman  should  do  no  heavy 
lifting  or  arduous  work  for  months;  should  keep  her  bowels  freely 
opened,  avoiding  constipation  and  its  attendant  straining  in  defeca- 
tion; and  should  wear  no  tight  clothing  which  causes  downward 
pressure  on  the  pelvic  organs.  If  the  uterus  is  subinvoluted,  it  is 
well  for  the  patient  to  spend  much  time  in  bed  at  first.  She  should 
lie  flat  on  the  abdomen  or  in  the  Sims  posture  for  several  hours  each 
day,  and  may  assume  with  advantage  the  knee-chest  posture  for  ten 
or  fifteen  minutes  several  times  daily.  In  most  cases  no  operative 
treatment  is  required,  unless  demanded  by  complicating  lesions. 
Innumerable  operations  have  been  devised  to  hold  the  uterus  forward 
(hysteropexy).  Shortening  of  the  round  ligaments  in  the  inguinal  canal 
(Alexander,  1882)  presents  the  disadvantage  that  it  does  not  permit 
treatment  of  accompanying  pelvic  lesions;  there  are  exceedingly  few 


11 11 


sri;<  ;/•:/,')    OF   THE  FEMALE  GENITALS 


cases  in  which  it  is  indicated.  Intraperitoneal  shortening  of  the  round 
ligaments  is  preferable.  The  operation  may  be  done  as  follows:  A 
forceps  is  thrust  through  the  broad  ligament  from  its  posterior 
surface,  just  beneath  the  tube  and  close  to  the  uterus.  This  forceps 
then  grasps  the  round  ligament  about  5  cm.  from  its  uterine  end, 
and  draws  it  through  the  broad  ligament  (Fig.  L109).  The  other 
round  ligament  is  treated  similarly,  and  then  the  two  round  liga- 
ments are  sutured  to  each  other  and  to  the  posterior  wall  of  the 


Fig.  1109. — Hysteropexy:  both  round  ligaments  have  been  pulled  through  the  broad 
ligaments,  and  are  about  to  be  sutured  to  each  other  and  to  the  fundus  of  the  uterus. 
(Baldy.) 

uterus  just  back  of  the  fundus  (Webster,  1901 ;  Baldy,  1903).  If  they 
are  sutured  too  low  on  the  uterus  they  will  pull  the  cervix  forward 
and  increase  the  retro-displacement  of  the  fundus.  V  entro-suspension 
of  the  nterus  consists  in  suturing  the  fundus  to  the  anterior  abdominal 
wall,  with  absorbable  sutures;  if  non-absorbable  sutures  are  used,  the 
operation  is  known  as  Ventro-fixation.  The  operation  should  not  be 
done  in  any  patient  wrho  has  not  reached  the  menopause.  It  is  very 
seldom  indicated  except  as  an  incident  in  the  operative  treatment  of 
genital  prolapse  in  the  female. 


PROLAPSE  OF   THE   UTERUS 


1145 


Downward  Displacement. — Usually  this  is  a  sequel  of  retrodisplace- 
ment.  When  the  axis  of  the  uterus  is  changed  so  that  it  corresponds 
with  that  of  the  vagina,  descent  is  almost  invariably  the  sequel.  It 
is  predisposed  to  by  loss  of  support,  the  result  of  lacerations  of  the 
pelvic  floor  and  perineum,  or  of  the  atrophy  which  sets  in  about  the 
time  of  the  menopause;  and  by  increased  pressure  from  above,  such 
as  tumors  of  the  uterus  or  abdominal  organs,  obesity,  tight  lacing, 
straining  in  defecation,  etc.  Several  degrees  of  descent  of  the  uterus 
are  recognized:  in  prolapse  the  uterus  still  remains  in  the  vaginal 
canal,  usually  pushing  before  it  a  cystocele  or  rectocele  (Fig.  1110); 
while  in  procidentia  the  uterus  protrudes  from  the  vulva  (Fig.  1111). 
The  cervix  becomes  hypertrophied  from  passive  congestion  and  fric- 
tion, and  frequently  is  ulcerated.    The  anterior  vaginal  wall  is  pushed 


Fig.  1110. — Prolapse  of  the  uterus; 
large  rectocele;  also  hemorrhoids. 
Pennsylvania  Hospital. 


Fig.  1111. — Procidentia  uteri  and  ulcer- 
ation of  the  cervix.  Patient,  aged  thirty- 
six  years,  has  had  eight  children,  including 
one  set  of  twins.     Pennsylvania  Hospital. 


or  pulled  down  by  the  prolapsing  uterus,  and  anterior  colpocele,  or  even 
cystocele  (prolapse  of  the  bladder  through  the  anterior  vaginal  wall) 
results.  Residual  urine  collects  in  the  bladder  pouch,  and  digital 
pressure  may  be  necessary  to  secure  evacuation  of  urine.  The  occur- 
rence of  posterior  colpocele  and  rectocele  has  been  discussed  at  p.  1139. 

Treatment  involves  (1)  repair  of  the  anterior  vaginal  wall;  (2) 
repair  of  the  pelvic  floor  and  perineum;  and  frequently  also  (3)  some 
intra-abdominal  operation  to  secure  the  uterus  in  a  position  of  ante- 
version,  thus  restoring  the  normal  relation  of  the  axis  of  the  uterus 
to  that  of  the  vagina;  (4)  if  the  cervix  is  very  large  it  should  be 
amputated  as  the  first  step  of  the  operation  (p.  1130). 

Repair  of  the  anterior  vaginal  wall  may  be  done  by  making  a  median 
incision  from  just  back  of  the  urinary  meatus  to  a  point  about  2.5  cm. 
in  front  of  the  cervix;  here  the  incision  diverges  in  two  branches,  so 
as  to  form  an  inverted  Y.    This  incision  is  carried  through  the  mucosa 


1146 


SURGERY  OF   THE  FEMALE  GENITALS 


exposing  the  muscular  wall  of  the  bladder.  The  mucous  flaps  are  then 
reflected  laterally  by  gauze  dissection,  until  the  operator's  finger 
can  detect  the  margins  of  the  rent  in  the  vesicovaginal  fascia  through 
which  the  hernia  of  the  bladder  has  occurred.  These  fascial  margins 
are  then  sutured  together  in  the  mid-line  by  buried  mattress  sutures 
of  chromic  gut,  taking  care  not  to  penetrate  the  bladder.  If  no  such 
margins  can  be  detected,  the  sutures  should  at  any  rate  be  passed  as 
far  laterally  as  possible,  through  the  outer  layers  of  the  vesical  wall, 
infolding  this  upon  itself  and  thus  overcoming  the  prolapse  of  the 
bladder.  The  flaps  of  vaginal  mucosa  are  now  to  be  sutured;  if 
redundant  the  excess  may  be  excised. 

The  operation  for  the  repair  of  a  cystocele  never  is  efficient  unless 
supplemented  by  repair  of  the  pelvic  floor  and  perineum,  as  already 
described  (p.  1140). 

In  cases  where  the  uterus  is  diseased  and  has  to  be  removed,  great 
care  should  be  taken  to  implant  the  stumps  of  the  broad  and  round 
ligaments  into  the  remains  of  the  cervix  or  the  vaginal  vault,  to  prevent 
prolapse.  In  severe  or  recurrent  cases  the  cervical  stump  may  be 
implanted  in  the  abdominal  wall. 

Genital  Fistulae. — Most  cases  of  genital  fistula?  in  the  female  result 
from  separation  of  sloughs  which  have  been  produced  by  prolonged 

or  excessive  pressure  during  partu- 
rition. They  are  rare  at  the  present 
day,  owing  chiefly  to  the  advances 
in  obstetrics.  Some  occur  as  the 
result  of  careless  operating  (Fig. 
1112),  and  others  from  ulceration 
due  to  inflammation  or  malignant 
disease.  All  except  the  latter  usu- 
ally may  be  cured  by  operative 
treatment.  By  far  the  commonest 
form  of  fistula  is  the  vesicovaginal; 
other  fistula?  (vesicouterine,  recto- 
vaginal, rectouterine,  ureterocervical , 
etc.)  are  comparatively  very  rare. 
The  diagnosis  depends  on  the  recog- 
nition of  the  leakage  of  urine  or 
fecal  matter  (or  even  merely  flatus) 
into  the  genital  tract.  Injection  of 
the  bladder  or  rectum  with  colored 
fluids  (milk,  methylene  blue,  etc.) 
renders  this  fact  certain.  In  most 
cases  the  fistula  can  be  brought  to  view  by  use  of  a  speculum. 
Uterine  fistula?,  however,  cannot  be  thus  exposed. 

Treatment. — Preparatory  treatment  before  operation  is  of  the 
utmost  importance.  The  phosphatic  deposit  of  urinary  salts  around 
the  margins  of  the  fistula  must  be  removed  gently,  and  their  reforma- 
tion prevented  by  rendering  the  urine  acid.     The  patient  must  drink 


Fig.  1112.  — •  Recto-vaginal  (recto- 
vestibular)  fistula  following  attempted 
repair  of  a  laceration  of  the  perineum. 
Pennsylvania  Hospital. 


GENITAL  FISTULA 


1147 


plenty  of  water;  copious  hot  vaginal  douches  should  be  given  to  cleanse 
the  parts,  and  the  dermatitis  of  the  vulva  and  adjacent  skin  should 
also  be  relieved  by  appropriate  remedies.  After  operation  the  patient 
remains  in  bed  about  three  weeks,  and  for  the  first  two  weeks  constant 
vesical  drainage  is  assured  by  the  use  of  an  inlying  catheter  (prefer- 
ably glass,  with  appropriate  curve),  which  must  be  changed  frequently. 
1.  When  the  fistulous  tract  can  be  exposed  from  below,  it  is  usually 
possible  to  close  it  by  a  plastic  operation.  The  edges  of  the  fistula 
are  pared  obliquely,  at  the  expense  of  its  vaginal  surface,  and  in  an 
oval  form  (Fig.  1113).    The  flap-splitting  method  seldom  is  required. 


Fig.  1113. — Vesicovaginal  fistula,  showing  the  proper  area  of  denudation.      Left 
lateroprone  position;  exposure  by  Sims'  speculum.     (Dudley.) 

2.  When  the  fistulous  tract  cannot  be  exposed  from  below,  as  is  usually 
the  case  in  fistula?  which  involve  the  uterus,  laparotomy  becomes 
necessary.  The  bladder  is  carefully  separated  from  the  uterus,  and 
the  opening  in  each  repaired  separately.  Hysterectomy  may  render 
the  operation  easier  or  the  cure  more  certain. 

Extra-uterine  Pregnancy.— Ectopic  gestation  usually  occurs  in  the 
tube,  and  in  most  cases  rupture  of  the  tube  occurs,  or  the  embryo 


II  IX 


SURGER1    OF   Till':   FEMALE  GENITALS 


is  discharged  into  the  peritoneal  cavity  through  the  fimbriated  ex- 
tremity of  the  tube  (tubal  abortion),  from  the  sixth  week  to  the  third 
month  of  pregnancy.  Occasionally  rupture  occurs  into  the  cellular 
tissue  of  the  broad  ligament;  this  is  least  unusual  when  pregnancy 
occurs  in  the  tube  close  to  the  uterine  wall  (ampullar  pregnancy), 
or  as  an  interstitial  pregnancy  in  that  portion  of  the  tube  within  the 
uterine  wall.  In  the  latter  ease  an  intra-uterine  abortion  may  occur. 
After  rupture  or  tubal  abortion  the  embryo  usually  dies,  but  in  rare 
cases  it  continues  to  grow  (secondary  abdominal  pregnancy)  almost 
to  full  term  (Fig.  111:)'. 

The  causes  of  extra-uterine  pregnancy  are  obscure.  It  occurs 
oftenest  in  women  who  have  been  sterile  for  five  years  or  more,  and 
is  thought  to  be  predisposed  to  by  previous  attacks  of  salpingitis, 
or  congenital  peculiarities  of  the  tube  (long  and  tortuous,  with  small 
lumen   or  with   diverticula). 


Fig.  1114. — -Ruptured  tubal  pregnancy;  an  eight  weeks'  fetus.  Age  twenty-three 
years,  one  childbirth,  four  years  ago;  had  missed  one  period,  and  had  had  premonitory 
symptoms  for  three  days.  Admitted  to  hospital  with  diagnosis  of  peritonitis;  pulse, 
150;  temperature,  98°  F. ;  leukocytes,  45,000;  polynuclears,  94  per  cent.;  hemoglobin, 
35  per  cent.  Correct  diagnosis  based  on  anemia.  Operation  fifteen  hours  after  rupture. 
Recovery.    Episcopal  Hospital. 


Symptoms  and  Diagnosis. — The  usual  early  symptoms  of  normal 
pregnancy  may  or  may  not  be  present;  these  include  particularly, 
morning  sickness,  increase  in  size  of  breasts,  perhaps  with  pigmenta- 
tion. In  almost  all  cases  there  is  a  disturbance  of  the  normal  menstrual 
periodicity:  often  one  period  is  missed  and  this  is  followed  in  a  week 
or  so  by  irregular  and  scanty  bleeding.  Painful  cramps  may  or  may 
not  occur  in  the  uterus.  If  vaginal  examination  is  made,  the  presence 
of  a  mass  in  the  tube  usually  can  be  determined.  It  may  be  difficult 
to  distinguish  this  from  a  pyosalpinx,  but  in  the  latter  there  should 


EXTRA-UTERINE  PREGNANCY 


1149 


be  no  concomitant  symptoms  or  signs  of  pregnancy.  In  ectopic 
gestation  the  uterus  usually  is  somewhat  enlarged  and  the  cervix  is 
softened.  In  the  vast  majority  of  cases  the  patient  does  not  come 
under  the  care  of  a  physician  until  rupture  of  the  tube  occurs.  This 
is  attended  by  agonizing  pain,  frequently  so  severe  as  to  cause  faint- 
ness,  and  is  followed  by  more  or  less  profuse  internal  hemorrhage 
evidenced  by  the  usual  signs.  Indeed,  symptoms  of  severe  internal 
hemorrhage  in  a  woman  previously  in  good  health  almost  always 
are  due  to  the  rupture  of  an  ectopic  gestation  sac.  In  a  minority  of 
cases  the  bleeding  occurs  so  slowly  that  no  very  acute  symptoms  are 
produced,  and  the  blood  collects  in  the  broad  ligament  (extraperi- 
toneally)  as  a  pelvic  hematocele.1  This  should  be  treated  by  vaginal 
puncture  (p.  1154),  and  later  by  laparotomy  if  necessary. 


Fig.  1115. — Secondary  abdominal  pregnancy  (four  or  five  months  fetus).  The 
history  indicated  that  tubal  rupture  occurred  when  pregnancy  was  six  weeks  advanced. 
Three  months  later  profuse  internal  hemorrhage  developed  after  coitus  (detachment  of 
placenta  from  its  abdominal  site).  Operation  (twelve  hours  later)  failed  to  avert  death. 
Episcopal  Hospital. 


Treatment. — If  the  condition  is  recognized  before  rupture  or  tubal 
abortion  occurs,  the  affected  tube  should  be  removed  at  once.  Exactly 
the  same  treatment  is  required  when  rupture  has  occurred.  Some 
authorities,  notably  Simpson  of  Pittsburgh,  contend  that  the  hemor- 
rhage always  will  cease  of  itself,  and  that  no  operation  should  be  done 
until  the  symptoms  indicate  that  this  has  taken  place.  The  majority 
of  surgeons  and  gynecologists,  however,  still  believe  that  less  risk  is 
run  by  immediate  operation,  even  in  the  presence  of  profound  shock 
from  hemorrhage,  than  by  delay.  Very  little  anesthetic  is  required. 
The  abdomen  is  rapidly  opened  above  the  pubes,  the  hand  is  intro- 
duced and  feels  for  the  uterine  appendages;  usually  there  are  no 
adhesions,  and  it  is  very  easy  to  tell  by  the  sense  of  touch  which  is 
the  affected  tube,  even  if  this  has  not  been  ascertained  before  opening 
the  abdomen.    The  ruptured  tube  is  brought  into  the  wound  and  the 

1  Rupture  of  a  retention  cyst  of  the  ovary  occasionally  is  followed  by  severe  interna] 
hemorrhage  which  may  be  indistinguishable  from  that  due  to  ruptured  tubal  gesta- 
tion (p.  1155).  1  have  encountered  two  such  cases.  The  treatment  is  the  same 
as  for  ruptured  extra-uterine  pregnancy. 


llf)0  SURGERY  OF   THE  FEMALE  GENITALS 

bleeding  temporarily  checked  by  the  fingers.  The  diseased  tube, 
usually  with  its  corresponding  ovary,  is  then  removed;  the  clotted 
and  semi-fluid  blood  is  removed  by  forceps  and  gentle  sponging, 
but  no  irrigation  is  employed.  It  is  well  to  pass  the  hand  into  each 
kidney  pouch  and  evacuate  the  clots  which  have  accumulated  there. 
If  the  operation  is  done  soon  after  rupture,  and  if  most  of  the  effused 
blood  and  clot  can  be  removed,  the  wound  may  be  closed  without 
drainage.  In  late  cases,  especially  if  there  is  any  suspicion  of  secondary 
infection  of  the  clot  from  the  adjacent  intestinal  tract  (not  very  rare) 
it  is  safer  to  drain  the  pelvis  for  a  few  days.  Bilateral  tubal  pregnancy 
may  occur,  and  it  is  always  desirable  to  examine  both  tubes  before 
closing  the  abdomen. 

Puerperal  Sepsis. — Many  cases  of  septic  infection  develop  from 
the  genital  tract  during  parturition  and  the  puerperium.  This  is 
owing  chiefly  to  the  ignorance  and  carelessness  of  midwives  or  incom- 
petent general  practitioners;  but  sometimes  it  is  unavoidable,  being 
due  solely  to  a  preexistent  infection,  or  to  self-induced  abortion. 
The  prevention  of  such  infection  is  in  the  realm  of  obstetrics;  but  its 
treatment  frequently  falls  to  the  lot  of  the  general  surgeon,  and  it 
behooves  him  to  be  prepared  to  give  the  best  treatment  that  is  known 
for  these  unfortunate  patients. 

The  infection  usually  takes  its  origin  at  the  placental  site  or  in  the 
lacerated  cervix;  occasionally  from  lacerations  in  the  vagina  or  at 
the  vulvar  orifice.  If  fetal  products  are  retained,  and  become  infected 
by  putrefactive  microorganisms,  sapremia  develops  (p.  72).  This 
is  commoner  than  invasion  by  pathogenic  bacteria,  resulting  in  sep- 
ticemia; the  latter  may  arise  as  a  secondary  condition  in  a  case  of 
sapremia,  but  more  often  is  a  primary  condition.  Finally,  if  septic 
thrombosis  occurs,  with  the  lodgement  of  secondary  emboli,  the  con- 
dition is  described  as  puerperal  pyemia. 

Retained  Secundines.  —  It  may  happen  after  labor  (particularly 
in  cases  of  miscarriage  or  abortion)  that  some  of  the  fetal  tissues  are 
retained.  The  question  arises  whether  their  expulsion  shall  be  left 
to  nature,  or  whether  they  shall  be  removed  by  a  surgeon.  While 
there  is  no  doubt  that  in  a  great  many  such  cases  the  unaided  power 
of  nature  is  sufficient,  yet  I  think  surgical  intervention  hastens  con- 
valescence, and  is  to  be  recommended  provided  it  is  certain  that 
secundines  have  been  retained  for  several  days.  If  this  fact  is  uncer- 
tain, as  it  is  in  a  great  many  cases,  it  is  better  to  wait  several  days 
longer  and  to  evacuate  the  uterus  surgically  only  when  evidences  of 
sapremia  become  manifest. 

Sapremia. — Local  changes  are  confined  mostly  to  the  endometrium 
(putrid  endometritis)  which  is  covered  with  brownish-gray  pulpy 
sloughs,  with  exceedingly  foul  odor.  Sapremia  occurs  oftenest  after 
full  term  labors  or  miscarriages  near  term.  Symptoms  usually  do 
not  appear  until  the  fourth  day  or  later,  and  consist  essentially  in 
elevation  of  temperature  (perhaps  as  high  as  105°)  and  other  phe- 
nomena of  fever,  with  foul  smelling  discharge  from  the  cervix. 


PUERPERAL  SEPSIS 


1151 


Treatment. — As  soon  as  such  symptoms  manifest  themselves,  the 
uterus  should  be  completely  evacuated.1  This  is  best  done  by  the 
gloved  finger,  covered  with  gauze,  or  with  the  placental  forceps,  if 
the  cervix  will  not  admit  the  finger  easily.  No  curette  should 
be  used.  It  is  very  easy  to  perforate  the  puerperal  uterus, 
especially  if  diseased.  The  surgeon  should  adopt  some  system  in 
cleaning  out  the  uterus,  and  should  make  sure  that  no  large  mass  of 
decomposing  tissue  is  left  behind.  On  several  occasions  I  have  been 
forced  to  repeat  the  operation  for  persistence  of  symptoms,  removing 
large  masses  of  foul  smelling  necrotic  placenta  which  had  been  over- 
looked by  the  previous  operator.  If  bleeding  is  free,  the  uterine  cavity 
should  be  packed  with  iodoform  gauze,  which  is  left  in  place  for  two 
days;  and  a  full  dose  of  ergot  should  be  administered.  If  no  note- 
worthy bleeding  occurs,  a  gauze  wick  may  be  left  within  the  cervix, 
or  if  this  tends  to  contract  too  much  to  permit  free  drainage,  a  rubber 
tube  should  be  passed  through  the  cervix  into  the  uterine  cavity. 

After  prompt  evacuation  of  such  a  uterus  the  temperature  rapidly 
falls,  and  uninterrupted  convalescence  is  the  rule  (Fig.  31,  p.  72). 

If  perforation  of  the  uterus  is  suspected,  the  uterine  cavity  should 
be  lightly  packed  with  gauze,  and  subsequent  developments  awaited. 
If  perforation  is  certain,  and  especially  if  the  operator  has  dragged  down 
bowel,  mistaking  it  for  retained  placental  tissues,  the  abdomen  should 
be  opened  at  once  (by  a  competent  surgeon),  and  the  damage  repaired. 

Septicemia. — This  may  occur  after  full  term  parturition  (especially 
if  instrumental),  but  is  most  frequent  as  the  result  of  criminal  abor- 
tions in  the   early  months  of 


pregnancy.  There  is  septic  en- 
dometritis, with  adherent  false 
membrane  over  denuded  areas, 
and  purulent  blood-stained  dis- 
charge, almost  always  accom- 
panied by  acute  septic  metritis, 
evidenced  by  an  edematous 
boggy  uterus.  Infection  may 
spread  to  the  peritoneum  (peri- 
metritis, acute  septic  pelvic  peri- 
tonitis, Fig.  1116)  and  to  the 
subperitoneal  cellular  tissues 
(parametritis,  acute  septic  pelvic 
cellulitis).  The  blood  sinuses  in 
the  uterine  walls  become  the 
seat  of  septic  thrombosis,  and  this 
may  extend  to  the  uterine  and 
ovarian  veins,  resulting  event- 
ually in  puerperal  pyemia  (see 
below).     Perivascular  lymphan- 


Fig.  1116. — Puerperal  sepsis:  Pelvic  peri- 
tonitis with  suppurative  perimetritis,  and 
parametritis.     (After  de  Quervain.) 


1  It  is  needless  to  say  that  all  such  patients  should  be  sent  to  a  well-equipped 
hospital  and  put  in  charge  of  a  competent  surgeon.  But  etherization  is  not  always 
necessary. 


1152  SURGERY  OF   THE  FEMALE  GENITALS 

geitis  may  occur,  and  if  extension  of  the  thrombus  to  the  external 
iliac  and  femoral  veins  takes  place,  "milk  leg"  results  (p.  272). 

Symptoms. — The  onset  of  puerperal  septicemia  occurs  earlier  than 
that  of  sapremia,  usually  on  the  second  or  third  day  after  delivery. 
The  disease  often  is  ushered  in  by  a  chill,  and  the  constitutional 
symptoms  are  much  more  severe  than  the  local.  The  temperature 
rises  to  great  heights  and  falls  again  rapidly  and  at  irregular  intervals 
(Fig.  28,  p.  70);  the  pulse  is  persistently  rapid  and  weak.  Chills  may 
occur  only  once  or  twice  in  the  course  of  the  disease,  or  several  times 
daily,  but  at  irregular  intervals.  Frequent  chills  usually  indicate 
pyemia.  Unless  peritonitis  sets  in,  and  except  during  the  chills,  the 
patient  suffers  little;  often  she  feels  quite  well,  except  for  weakness, 
even  when  most  gravely  ill.  There  may  be  little  found  in  the  pelvis 
to  account  for  the  symptoms:  usually  the  uterus  is  larger  than  normal, 
and  the  discharge  may  be  purulent,  but  it  does  not  possess  the  foul  odor 
characteristic  of  putrefaction,  unless  sapremia  was  the  primary  condi- 
tion. Early  in  the  disease  the  uterus  is  not  fixed,  and  the  abdomen 
usually  is  soft  and  full.  Only  if  salpingitis  or  pelvic  peritonitis  exists  is 
there  local  rigidity  and  tenderness.  It  is  when  the  infection  is  confined 
to  the  extraperitoneal  structures  (pelvic  cellulitis),  that  the  patient  feels 
so  well  subjectively.  By  the  end  of  the  first  week  of  the  disease, 
rarely  earlier  and  often  much  later,  the  uterus  may  become  fixed, 
and  a  pelvic  mass  may  be  detected.  In  some  cases  during  the  second 
or  third  week  the  thrombosed  uterine  and  ovarian  veins  may  be 
palpated  in  the  broad  ligament. 

Treatment. — In  every  case  I  believe  it  is  well  to  make  sure  that  the 
uterus  retains  no  necrotic  material.  Indeed  it  must  be  confessed  that 
the  diagnosis  between  sapremia  and  septicemia  often  cannot  be  made 
until  after  the  uterine  cavity  has  been  explored.  If  necrotic  material 
is  found,  and  rapid  improvement  follows  its  removal,  it  usually  is 
safe  to  assume  that  the  condition  wTas  one  of  sapremia;  if  on  the  other 
hand,  septic  symptoms  continue  it  is  evident  that  the  infection  has 
entered  the  uterine  walls  and  has  become  systemic.  Attempts  have 
been  made  to  eradicate  the  entire  focus  of  disease  in  these  cases  by 
prompt  removal  of  the  uterus;  but  the  mortality  following  the  opera- 
tion is  too  high  to  justify  its  employment  at  this  stage.  Some  wreeks 
or  months  later  hysterectomy  may  be  necessary,  to  remove  a  uterus 
riddled  with  abscesses. 

As  early  as  possible  cultures  should  be  made  from  the  interior  of  the 
uterus.  In  most  cases  the  streptococcus  is  the  infecting  organism; 
and  if  the  patient  is  seen  early  enough  (within  two  or  three  days  of 
onset)  it  may  be  worth  while  to  employ  large  doses  of  antistreptococcic 
serum,  or  a  polyvalent  serum  intravenously.  But  unless  massive 
doses  (50  to  150  c.c.  in  twenty-four  hours)  are  employed  early  in  the 
disease,  this  remedy  appears  to  be  useless.  Harrar  (1913)  uses  intra- 
venously a  2  per  cent,  solution  of  chemically  pure  magnesium  sulphate 
in  freshly  distilled  water  (giving  100  to  200  c.c.  at  the  first  dose,  and 
increasing  to  400  c.c.)  at  intervals  of  two  or  three  days. 


PUERPERAL  SEPSIS 


1153 


Further  than  this,  nothing  remains  but  to  provide  careful  nursing; 
to  ensure  the  taking  of  plenty  of  proper  nourishment  and  abundance 
of  water  (continuous  proctoclysis,  hypodermoclysis,  etc.);  and  to 
watch  the  pelvic  condition.  Vaginal  examinations  should  be  made 
not  oftener  than  once  in  three  days;  great  gentleness  should  be  used, 
and  note  should  be  made  of  the  mobility  of  the  uterus,  the  presence 
of  a  mass,  or  of  thrombosed  ovarian  veins.  A  pelvic  mass  under  these 
circumstances  is  placed  low  in  the  pelvis,  fixed  to  the  uterus,  and  usually 
on  one  side  or  the  other,  though  often  extending  behind  the  cervix. 
Sometimes  the  abscess  tends  to  point  above  Poupart's  ligament  (Fig. 
1117).  Many  authorities  consider  that  all  such  abscesses  have  their 
origin  in  the  pelvic  cellular  tissues,  and  are  entirely  extraperitoneal. 


Fig.  1117.  —  Puerperal  sepsis:  pelvic 
abscess  extending  low  in  the  pelvis  and 
pointing  above  Poupart's  ligament.  (After 
de  Quervain.) 


Fig.  1118. — Double  pyosalpinx,  with 
moderate  serous  perisalpingitis.  The 
masses  are  placed  higher  in  the  pelvis 
than  those  which  result  from  puerperal 
sepsis.     (After  de  Quervain.) 


Some  of  them  I  am  sure  are  ordinary  residual  pelvic  abscesses,  the 
sequel  of  diffuse  peritonitis.  The  distinction  is  of  little  practical 
importance,  but  a  very  important  point  is  to  open  all  such  masses 
without  invading  the  healthy  peritoneal  cavity.  A  pelvic  mass  the  result 
of  gonococcic  infection  (pyosalpinx,  tubo-ovarian  abscess)  is  placed 
higher  in  the  pelvis,  and  its  onset  does  not  date  from  an  instrumental 
delivery  or  a  miscarriage  (Fig.  1118).  Such  an  abscess  may  be  opened 
transperitoneally  with  safety,  providing  the  operation  is  not  done  for 
several  weeks  after  the  acute  onset  (p.  1132).  But  abscesses  which 
result  from  puerperal  infection  usually  are  streptococcic  in  origin,  and 
if  the  peritoneum  is  opened,  even  many  weeks  after  the  acute  onset, 
fatal  peritonitis  may  develop.  The  abscess  should  be  incised  through 
73 


L154  SURGERY  OF   THE  FEMALE  GENITALS 

the  posterior  vaginal  vault,  or  above  Poupart's  ligament.  No  opera- 
tion should  be  undertaken  as  a  mere  exploration,  but  only  when  the 
existence  of  suppuration  is  fairly  certain. 

Vaginal  Puncture. — The  cervix  is  pulled  down  and  forward  by 
volsellum  forceps,  and  a  transverse  incision  is  made  about  5  cm. 
long,  just  posterior  to  the  cervix.  When  the  vaginal  wall  has  been 
incised,  the  knife  is  laid  aside,  and  the  abscess  is  opened  by  the  finger, 
or  by  Hilton's  method  (p.  50).  The  cavity  is  drained  by  gauze  and 
rubber  tube. 

Extraperitoneal  Incision. — If  the  abscess  points  near  Poupart's 
ligament,  it  is  easily  evacuated  through  a  small  McBurney  incision. 
When  the  layers  of  the  abdominal  wall  have  been  incised,  great  care 
is  required  not  to  injure  the  peritoneum,  or  to  break  up  isolating 
adhesions  if  the  abscess  is  intraperitoneal  in  origin.  The  surgeon 
should  burrow  down  cautiously  along  the  pelvic  wall  until  pus  is 
found.     The  abscess  cavity  is  then  drained  by  rubber  tube  and  gauze. 

Pyemia. — Puerperal  pyemia,  as  already  noted,  results  from  the 
detachment  of  septic  emboli  in  the  peri-uterine  veins.  Repeated 
chills,  and  the  appearance  of  metastatic  foci  of  infection  are  the 
two  main  diagnostic  points.  Embolic  pneumonia  is  frequent.  Other 
foci  are  less  usual,  but  recovery  may  ensue  after  multiple  arthritis, 
conjunctivitis,  subcutaneous  abscesses,  and  even  after  cerebral 
embolism. 

Treatment. — When  thrombosed  ovarian  veins  can  be  felt  on  vaginal 
examination,  and  the  clinical  symptoms  of  pyemia,  especially  recurring 
chills,  are  present,  it  has  been  proposed  to  open  the  abdomen  and 
ligate  the  veins  above  the  limits  of  thrombosis,  or  even  to  excise  the 
infected  thrombi,  as  is  done  in  jugular  thrombosis  (p.  621).  The 
operation,  though  it  may  be  difficult,  is  seldom  impossible;  but  some- 
times the  thrombus  is  found  to  extend  so  high  (to  the  renal  veins 
or  vena  cava)  or  may  involve  so  many  trunks  (internal,  common  and 
external  iliac),  that  the  operation  will  have  to  be  abandoned.  But 
as  the  mortality  following  this  operation,  in  collected  statistics,  varies 
from  20  to  55  per  cent.,1  and  the  general  mortality  of  the  condition 
for  which  it  is  recommended  is  from  55  to  80  per  cent.,  in  cases  treated 
without  operation,  it  is  apparent  that  in  carefully  selected  cases  it  is 
a  procedure  worthy  of  careful  consideration. 

TUMORS    OF   THE   FEMALE   GENITAL   TRACT. 

Ovarian  and  Parovarian  Cysts  and  Tumors. — Ovarian  Cysts  may 
be  classified  as  retention  cysts  and  cystadenomas.  Dermoid  cysts 
(teratomas)  are  discussed  at  p.  1158. 

Retention  Cysts  of  the  Ovary. — Reference  has  already  been  made, 
at  p.  1135,  to  cystic  degeneration  of  the  ovaries,  usually  associated  with 
chronic  ovaritis,  and  probably  due  to  thickening  of  the  stroma;  the 

1  Michels  in  1909  collected  64  such  operations,  with  31  deaths  (48  per  cent.); 
but  J.  W.  Williams  (1909)  reported  5  cases  in  his  own  experience  with  only  1  death. 


OVARIAN  AND  PAROVARIAN  CYSTS  1155 

cysts  usually  are  small,  multiple,  and  appear  not  only  on  the  surface 
of  the  ovary,  but  are  scattered  throughout  its  structure  (Fig.  109S). 
Apart  from  the  associated  lesions,  they  produce  no  symptoms  and 
require  no  treatment. 

A  retention  cyst  of  the  Graafian  follicle  usually  is  larger  than  the 
cysts  found  in  cystic  degeneration  of  the  ovary;  it  almost  always  is 
single,  and  is  attached  to  the  ovary  by  a  rather  wide  base.  It  is  lined 
by  cylindrical  epithelium,  but  in  the  larger  cysts  this  becomes  atrophied 
from  pressure.  If  it  is  large  enough  to  produce  symptoms,  the  differ- 
ential diagnosis  from  tubal  and  other  ovarian  enlargements  becomes 
important.  Usually  it  is  found  to  be  the  size  of  a  hen's  egg  or  small 
orange,  and  freely  movable  in  the  pelvis,  though  attached  by  a  pedicle 
to  the  uterus.  Its  contents  are  clear,  unless  blood-stained  from  intra- 
cystic  hemorrhage.  Intraperitoneal  rupture,  with  or  without  bleeding, 
may  occur;  and  if  bleeding  is  profuse  the  condition  resembles  that 
seen  in  ruptured  ectopic  pregnancy  and  requires  the  same  treatment. 
Excision  of  the  cyst  and  suture  of  the  defect  in  the  ovary  is  the  proper 
treatment  •  for  the  unruptured  cyst;  removal  of  the  entire  ovary  is 
undesirable  unless  the  patient  has  reached  the  menopause. 

The  corpus  luteum  cyst  is  another  type  of  retention  cyst  of  the  ovary. 
The  contents  usually  are  dark  and  tarry,  and  the  cyst  wall  is  not 
tense.  Without  histological  examination,  which  shows  typical  lutein 
cells  (pigmented  round  cells)  but  no  epithelium  in  the  lining  membrane, 
the  diagnosis  from  the  Graafian  follicle  cyst  is  uncertain.  The  cyst 
should  be  excised  and  the  defect  in  the  ovary  sutured. 

Tubo-ovarian  Cysts  may  occur  in  connection  with  any  variety  of 
ovarian  cysts,  but  are  especially  frequent  in  the  case  of  retention  cysts. 
They  may  follow  tubo-ovarian  abscess  (p.  1134). 

Cystadenomas  of  the  Ovary. — These  are  true  neoplasms.  Two  main 
varieties  are  recognized :  the  simple  {pseudomucinous)  cystadenoma,  and 
the  papuliferous  cystadenoma. 

Simple  Cystadenoma. — These  are  the  typical  "ovarian  cysts." 
Nowadays  they  rarely  reach  the  immense  size  formerly  encountered, 
when  the  tumor  not  infrequently  weighed  more  than  the  patient,  since 
operation  is  resorted  to  while  the  cysts  are  still  of  reasonable  size. 

Usually  only  one  ovary  is  affected.  The  cyst  originally  is  multi- 
locular,  but  the  smaller  cysts  frequently  coalesce  to  form  larger  com- 
partments, and  incomplete  partitions  may  be  the  only  evidence  of 
the  former  multilocular  state.  The  cyst  walls  are  lined  by  cylindrical 
epithelium  in  a  single  layer;  stratification  of  the  epithelium  is  rare  and 
may  indicate  a  malignant  tendency.  In  the  cyst  walls  are  found  down- 
growths  of  epithelium,  forming  simple  or  compound  gland  tubules. 
The  fluid  within  the  cysts  is  viscid,  glairy,  or  mucinous,  and  its  color 
varies  from  clear  yellow  to  turbid  or  brownish.  From  their  contents 
the  cysts  often  are  termed  pseudomucinous.  The  ovary  is  compressed, 
atrophied,  and  may  be  entirely  destroyed  by  the  pressure  of  the  cyst. 
The  two  most  frequent  complications  are  rupture  of  the  cyst,  and  torsion 
of  its  pedicle.     If  rupture  occurs  there  may  be  marked  shock,  but  this 


1156 


SURGERY  OF   THE  FEMALE  GENITALS 


is  rare;  usually  the  fluid  is  absorbed,  and  temporary  polyuria  may  be 
noted;  in  other  cases  peritonitis  develops.  Occasionally  after  rupture 
portions  of  the  cyst  lining  become  engrafted  in  various  parts  of  the 
abdominal  cavity,  and  numerous  small  cysts  develop  {pseudomyxoma 
peritonei).  Torsion  of  the  pedicle  is  a  very  serious  accident,  which  occurs 
in  about  10  per  cent,  of  cases.  It  is  especially  frequent  in  dermoid  cysts 
(p.  1158).  The  symptoms  are  severe  pain,  shock,  and  sudden  increase 
in  size  of  the  tumor  (perhaps  previously  not  known  to  exist).  This 
sudden  increase  in  size  results  from  venous  obstruction  in  the  pedicle, 
causing  serous  and  bloody  transudation  in  the  cyst.  If  the  twist 
is  tight  enough,  gangrene,  with  slowly  developing  peritonitis,  may 
occur.    Prompt  operation  is  indicated  in  all  cases. 


Fig.  1 119. — -Specimen  of  multilocular  cyst  of  the  ovary.     Weight  1950  grams  (4  pounds). 
Age  of  the  patient  twenty-six  years;  tumor  was  the  size  of  a  fetal  head. 


Even  if  no  complications  occur,  the  clinical  course  of  an  ovarian 
cyst  is  invariably  toward  the  death  of  the  patient.  Ovarian  cysts 
grow  rapidly,  and  usually  life  is  terminated  within  comparatively 
few  years  unless  the  cyst  is  removed  by  operation. 

Papuliferous  Cystadenoma. — This  growth  frequently  affects 
both  ovaries,  is  more  often  unilocular  than  multilocular,  often  develops 
between  the  layers  of  the  mesosalpinx,  and  rarely  attains  very  large 
size.  The  cyst  wall  is  lined  by  cylindrical-celled  epithelium,  usually 
not  stratified,  but  always  bearing  intracystic  papillomas.  The  con- 
tained fluid  is  thin  and  serous,  rarely  blood-tinged.  At  the  time  of 
operation  fully  50  per  cent,  of  these  tumors  are  already  carcinomatous, 
and  it  is  highly  probable  that  all  would  become  malignant  if  not 
removed.  The  continuous  growth  of  the  intracystic  papillomas  leads 
to  distention  of  the  cyst  and  frequently  causes  its  rupture,  whereupon 
the  growth  becomes  grafted  on  neighboring  structures  in  the  abdomen, 
and  ascites  frequently  results.  Secondary  myxomatous  or  calcareous 
degeneration  may  occur. 

Parovarian  Cysts. — The  parovarium  or  epoophoron  lies  in  the  broad 
ligament  between  the  ovary  and  Fallopian  tube.  It  is  formed  by 
the  remains  of  the  Wolffian  body  (Fig.  1120),  and  is  composed  of  a 
longitudinal  tube  {Gartner  s  duct),  and  transverse  tubules  which  run 


OVARIAN  AND  PAROVARIAN  CYSTS  1157 

from  the  hilum  of  the  ovary  to  join  the  longitudinal  tube.  The 
Hydatid  of  Morgagni,  which  is  present  in  about  50  per  cent,  of  females, 
is  recognized  as  the  lateral  continuation  of  the  longitudinal  duct;  it 
enters  the  broad  ligament  on  its  anterior  surface  between  Fallopian  tube 
and  ovary.  KobeWs  tubules  are  the  aberrant  tubules  of  the  Wolffian 
body  between  the  hydatid  of  Morgagni  and  those  tubules  which 
enter  the  hilum  of  the  ovary.  Any  of  these  tubular  structures  may 
become  the  seat  of  cystic  formation.  Cysts  arising  from  the  hydatid 
of  Morgagni  and  from  Kobelt's  tubules  usually  are  small,  are  attached 
to  the  lateral  border  of  the  broad  ligament  by  a  more  or  less  distinct 
pedicle,  and  seldom  produce  symptoms;  they  are  to  be  distinguished 
from  myxomatous  and  cystic  degeneration  of  the  fimbriae  of  the  Fal- 
lopian tube. 


. ...  ■  \  --^ ' 


Mor</ac///i  O  r  rr  r  .//      J  W'^ 


ffi/f/r/fid  of 


Fig.  1120. — Diagram  of  ovary  and  parovarium. 

The  typical  'parovarian  cyst  forms  about  10  per  cent,  of  all  cases  of 
ovarian  cyst.  It  develops  and  spreads  within  the  folds  of  the  broad 
ligament  (hence  it  is  known  as  the  "broad  ligament  cyst"),  almost 
always  is  unilocular,  grows  slowly,  and  seldom  attains  very  great  size. 
Its  contents  are  clear,  "like  spring  water,"  and  the  cyst  wall  is  lined 
with  a  single  layer  of  cylindrical  epithelium.  It  is  easily  distinguished 
from  an  ovarian  cyst  because  it  is  independent  of  the  ovary,  is  covered 
by  peritoneum,  possesses  a  double  layer  of  vessels  on  its  surface  (one 
belonging  to  the  peritoneum  and  the  other  to  the  cyst  wall),  usually 
is  easily  enucleated  (rarely  forming  adhesions),  possesses  no  distinct 
pedicle,  and  almost  invariably  has  the  Fallopian  tube  stretched  out 
over  its  surface  at  some  distance  from  the  ovary. 

Symptoms  and  Diagnosis  of  Ovarian  and  Parovarian  Cysts. — Few 
symptoms  are  present  unless  the  cyst  is  of  such  a  size  as  to  become 
impacted  in  the  pelvis,  or  unless  it  is  so  large  and  of  such  long  dura- 
tion as  to  have  induced  cachexia,  when  the  typical  fades  ovariana  is 
seen  (Fig.  1121).  In  most  cases  the  cyst  is  discovered  by  accident,  or 
the  woman  comes  to  the  surgeon  because  of  increase  in  size  of  the 
abdomen.  Ovarian  cysts  are  commonest  from  forty  to  fifty  years  of 
age. 

If  the  tumor  is  small  it  is  felt  as  a  smooth,  round,  tense,  fluctuating, 
movable,  and  usually  painless  tumor,  attached  to  the  uterus  by  a 


1 1  ;>s 


SURGERY  OF   THE   F E  MALE  GENITALS 


pedicle.    I  differential  diagnosis  from  other  tubo-ovarian  lesions  depends 
chiefly  on  the  clinical  history. 

//  the  fin/tor  is  of  medium  size  (fetal  to  adult  head)  it  usually  rises 
out  of  the  pelvis  and  is  appreciated  as  an  abdominal  growth.  The 
diagnosis  nnisl  be  made  from  uterine  fibroid  and  other  pelvic  tumors. 
The  cyst  lies  posterior  to  the  uterus  (a  distended  bladder  lies  in  front), 
and  it  often  is  possible  to  determine  that  the  uterus  is  of  normal  size. 
In  most  cases  the  pedicle  of  an  ovarian  cyst  can  be  detected,  but  this 
may  require  abdomino-rectal  palpation,  while  one  assistant  draws 
the  uterus  down  into  the  vagina  by  a  tenaculum  and  another  assistant 
draws  the  tumor  as  far  as  possible  out  of  the  pelvis  into  the  abdomen. 
If  a  pedicle  is  absent  (intraligamentary  cyst)  the  distinction  from  a 
subperitoneal  fibroid  may  be  very  difficult,  depending  chiefly  on  the 
clinical  history. 


Fig.  1121. — Malignant  suppurating  ovarian  cyst  in  a  woman,  aged  fifty-seven  years; 
duration  of  illness  seven  years.  Was  tapped  for  ascites  several  years  ago.  Tumor 
cystic  with  solid  masses;  abdominal  circumference,  with  patient  recumbent,  was 
125  cm.  Weight  149  pounds  (normal  weight  126  pounds).  Inoperable.  Episcopal 
Hospital. 


When  the  tumor  becomes  very  large,  ascites  is  the  chief  condition  which 
simulates  it.  But  in  ascites  there  usually  is  some  organic  cause  for 
the  condition,  and  the  latter  has  developed  suddenly;  the  abdomen 
is  fiat  on  the  top  and  bulging  in  the  flanks;  its  outline  does  not  rise 
abruptly  from  the  pubis  as  is  the  case  in  ovarian  cyst  (Fig.  1121); 
the  umbilical  area  is  resonant,  the  navel  pouts,  and  there  is  shifting 
dulness  in  the  flanks. 

Dermoid  Cysts  (Teratomas)  develop  from  the  germinal  cells  of  the 
ovary.  Under  this  term  are  classed  both  simple  dermoid  cysts,  which 
contain  only  normal  skin  products  (secretions  of  sweat  and  sebaceous 
glands,  hair,  nails,  and  teeth),  and  complicated  dermoid  cysts,  in  which 
may  be  found  also  bones,  cartilage,  muscle,  and  other  more  or  less 
fully  formed  structures  (embryomas).  Dermoid  cysts  frequently 
affect  both  ovaries,  and  may  begin  to  grow  at  any  age  (often  in  children 
and  young  girls).    When  growth  begins  it  usually  is  rapid;  but  if  the 


OVARIOTOMY 


1159 


cyst  remains  small  it  may  cause  no  symptoms  unless  it  becomes  infected 
or  undergoes  carcinomatous  change  (both  are  frequent  complications) 
and  may  last  for  a  lifetime.  Usually  the  cysts  are  adherent  and  should 
be  treated  as  if  malignant. 

Solid  Tumors  of  the  Ovary  are  comparatively  rare.  They  are 
frequently  bilateral.  The  most  important  are  the  malignant  tumors: 
the  carcinomas  clinically  resemble  the  papilliferous  cystadenomas;  in 
many  cases  they  are  secondary  to  carcinoma  elsewhere  (stomach,1 
breast,  uterus,  liver,  etc.)  being  grafted  on  the  germinal  epithelium 
of  the  ovary  through  the  medium  of  the  omentum.  Both  ovaries  may 
be  involved.  Blood-stained  ascitic  fluid  is  frequently  present.  Sar- 
coma usually  occurs  at  a  younger  age.  Of  the  benign  tumors,  fibroma 
is  most  often  encountered;  it  may  occur  at  an  early  age  (Fig.  1122), 
but  seldom  causes  symptoms  except  from  its  weight  or  from  pressure 
if  impacted  in  the  pelvis. 


Fig.  1122. — Fibroma  of  the  ovary  in  a  girl  aged  nineteen  years.  Diagnosis  was 
subacute  appendicitis,  and  the  ovarian  mass  with  an  unruptured  blood  cyst  was  dis- 
covered on  exploration.     Episcopal   Hospital. 

Treatment. — All  such  growths  should  be  removed,  unless  clearly 
inoperable. 

Ovariotomy. — This  is  the  classical  operation  for  the  removal  of  an 
ovarian  cyst  (Ephraim  McDowell,  1809).  If  the  cyst  is  so  small  as 
to  be  delivered  easily  through  an  ordinary  abdominal  incision,  the 
operation  resembles  that  described  as  oophorectomy2  or  salpingo- 
oophorectomy  (p.  1136);  the  tube  may  or  may  not  be  removed  with 
the  diseased  ovary.  But  in  cases  where  the  tumor  is  very  large,  the 
technique  of  the  operation  is  different.    A  hypogastric  paramedian  in- 

1  The  so-called  "Krukenberg  tumor"  of  the  ovary  (1896)  is  believed  by  Symmera 
(1917)  to  be  of  this  nature. 

2  This  of  course  is  a  more  correct  term  etymologically,  but  long  usage  sanctions 
the  use  of  the  term  ovariotomy  for  the  typical  operation  for  large  ovarian  cysts. 


L160  SURGERY  OF   THE  FEMALE  GENITALS 

cisioD  is  made,  and  the  peritoneal  cavity  opened;  if  thecyst  is  thought  to 
be  malignant  (papuliferous  cystadenoma,  dermoid)  every  effort  should 
be  made  to  prevent  its  rupture;  these  cysts  seldom  are  immensely 
large,  and  usually  may  be  delivered  through  an  incision  of  moderate 
size.  In  every  ease  of  malignancy  both  ovaries  should  be  removed. 
In  the  ease  of  an  immense  cyst,  however  (usually  a  simple  cystadenoma), 
it  is  best  to  tap  the  tumor  so  as  to  enable  it  to  be  removed  through 
an  incision  of  ordinary  size.  After  the  cyst  wall  is  exposed,  the  pre- 
senting surface  of  the  tumor  is  isolated  by  gauze  packs,  and  a  large 
blunt  pointed  cannula  (at  least  1  cm.  in  diameter)  with  rubber  tube 
attached,  is  thrust  into  an  avascular  area  of  the  cyst  wall,  and  the 
contents  are  removed  by  syphonage.  If  the  cyst  is  multilocular  it 
may  be  necessary  to  tap  several  loculi;  usually  a  sufficient  number 
may  be  reached  from  the  interior  of  that  first  emptied  without  with- 
drawing the  cannula.  As  the  cyst  walls  collapse  they  are  to  be  drawn 
into  the  wound  with  volsellum  forceps,  and  an  assistant  is  to  make 
pressure  on  the  flanks,  so  as  to  prevent  leakage  into  the  abdominal 
cavity.  When  the  entire  tumor  has  been  withdrawn  the  pedicle 
comes  into  view.  If  there  are  adhesions,  the  operation  is  much  more 
difficult,  and  careful  dissection  may  be  required  to  free  the  tumor  from 
omentum,  mesentery,  intestine,  etc.  When  the  pedicle  has  been 
brought  into  view,  it  should  be  caught  in  strong  crushing  forceps, 
and  ligated  by  transfixion  in  the  groove  thus  made.  The  pedicle 
usually  is  composed  of  broad  and  round  ligaments,  Fallopian  tube, 
and  infundibulo-pelvic  ligament.  Great  care  should  be  taken  to  see 
that  hemostasis  is  complete;  when  they  can  be  identified  the  ovarian 
and  utero-ovarian  arteries  should  be  tied  separately.  Finally  the 
stump  of  the  infundibulo-pelvic  ligament  should  be  united  to  the 
stump  of  the  tube,  and  denuded  areas  should  be  covered  by  peri- 
toneum.   Before  closing  the  abdomen  always  examine  the  other  ovary. 

If  the  intestines  are  carefully  protected  from  exposure  and  the 
patient's  bodily  heat  maintained,  the  operation  is  attended  by  very 
little  shock.    The  mortality  in  expert  hands  is  below  5  per  cent. 

Fibroids  of  the  Uterus. — These  tumors  are  fibro-myomas;  those 
with  an  excess  of  fibrous  tissue  justly  merit  the  term  fibroids,  but  in 
general  this  term  and  myoma  or  fibromyoma  are  used  indiscriminately, 
regardless  of  the  amount  of  fibrous  tissue  present  in  the  tumors.  The 
tumors  usually  are  multiple,  and  spring  from  the  uterine  wall,  prob- 
ably, it  is  believed,  from  the  walls  of  bloodvessels.  They  occur  with 
greatest  frequency  in  the  body  of  the  uterus,  fibroids  of  the  cervix 
being  comparatively  rare.  By  some  the  affection  is  considered  a  wide- 
spread disease,  with  one  of  its  local  manifestations  in  the  uterus;  and 
they  explain  the  frequently  accompanying  myocardial  changes  in  this 
way.  Some  authorities  teach  that  the  tumors  always  have  a  congenital 
origin;  it  is  undisputed,  however,  that  they  seldom  begin  to  produce 
symptoms  or  are  discovered  until  well  into  the  child-bearing  period, 
from  thirty-five  to  forty-five  years  of  age.  A  woman  with  fibroids 
usually  is  sterile,  and  it  is  disputed  whether  sterility  is  to  be  regarded 


FIBROIDS  OF  THE   UTERUS 


1161 


as  a  cause  or  a  result  of  the  existence  of  fibroids.  If  pregnancy 
occurs  it  is  very  apt  to  result  in  abortion  or  miscarriage.  Fibroids 
are  especially  common  in  the  negro  race. 


Fig.  1123. — Fibroids  of  the  uterus,  subperitoneal  and  interstitial;  age  fifty-three 
years.     (See  Fig.  1124.)     Episcopal  Hospital. 


Fig.  1124. — Uterine  fibroids,  specimen  shown  in  Fig.  1123  sectioned,  exposing  inter- 
stitial growths,  one  of  which  has  undergone  cystic  degeneration.  Note  also  carcinoma 
of  the  cervix,  with  its  crater-like  excavation;  a  rare  complication  of  fibroid  tumors. 
Episcopal  Hospital. 


1162  SURGERY  OF   THE  FEMALE  GENITALS 

The  tumors  begin  as  interstitial  growths,  within  the  walls  of  the 
uterus;  they  may  remain  in  the  uterine  wall  even  when  attaining  very 
large  size,  but  usually  they  tend  to  push  their  way  through  to  the 
subperitoneal  or  the  submucous  surface  of  the  uterus.  In  many  cases 
tumors  are  found  in  all  three  locations.  They  may  present  beneath 
the  peritoneum  or  mucosa  as  sessile  growths,  but  not  infrequently 
a  pedicle  forms.  Then  the  tumor,  if  subperitoneal,  may  become  adher- 
ent to  neighboring  abdominal  structures,  as  the  result  of  attacks  of 
congestion  and  inflammation  from  torsion  of  the  pedicle;  and  in  rare 
instances  these  secondary  adhesions  may  become  so  firm  that  the 
pedicle  ruptures  and  the  migrated  fibroid  continues  to  receive  its 
nourishment  through  the  adhesions  alone.  Submucous  fibroids 
frequently  develop  pedicles,  and  present  in  the  uterine  cavity  or  pro- 
trude from  the  cervix  in  the  form  of  polypi.  Usually  only  one  polypus 
is  present,  springing  from  the  cervix  or  near  it,  and  mostly  fibrous  in 
structure.  If  a  polypus  springs  from  the  fundus  of  the  uterus,  the 
uterine  wall  becomes  thinned  at  the  point  of  attachment,  and  inversion 
of  the  uterus  may  occur. 

Symptoms. — In  many  cases  no  symptoms  whatever  are  produced 
until  the  tumors  become  so  large  as  to  cause  pressure  effects.  Among 
the  most  usual  of  these  are  vesical  irritability,  hemorrhoids  and  inter- 
ference with  defecation,  pain  in  the  sacrum  and  coccyx,  varicose 
veins  or  edema  from  interference  with  the  circulation  of  the  lower 
extremities,  renal  disturbances  from  pressure  on  the  ureters,  etc. 
Interstitial  growths  may  cause  no  noticeable  change  in  the  form  of  the 
uterus,  though  it  may  be  much  larger  than  normal,  and  the  depth 
of  its  cavity  will  be  increased;  but  a  sound  should  not  be  introduced 
without  due  consideration,  particularly  until  the  possibility  of  preg- 
nancy has  been  absolutely  eliminated.  Dysmenorrhea  is  present  in 
some  cases  of  interstitial  growths.  Subperitoneal  groicths  usually 
may  be  recognized  by  bimanual  palpation;  they  may  be  of  various 
sizes  and  shapes,  but  are  attached  to  the  uterus,  move  with  it,  and 
usually  are  high  in  the  pelvis,  not  in  the  position  where  pus  tubes 
are  found;  unless  the  tumor  is  very  large,  or  impacted  in  the  pelvis, 
the  tumor  is  not  fixed.  Submucous  groicths  are  particularly  charac- 
terized by  profuse  and  prolonged  menstrual  bleeding;  intermenstrual 
hemorrhage  is  rare,  though  bleeding  may  last  from  one  period  to  the 
next  and  continue  through  this;  then  an  intermission  may  occur  until 
the  normal  time  for  the  occurrence  of  the  next  menstruation  which 
will  also  be  unduly  prolonged.  Anemia  is  a  frequent  result  and  may 
be  severe.  Sometimes  submucous  tumors  may  be  detected  by  the 
introduction  of  a  finger  into  the  os,  which  frequently  is  patulous. 
Attacks  of  colicky  pain  may  be  caused  by  efforts  of  the  uterus  to 
force  the  tumor  through  the  cervix.  Complications:  Occasionally  a 
large  submucous  fibroid  prolapses  through  the  vagina,  and  may  cause 
inversion  of  this  structure  or  even  of  the  uterus  itself.  Strangulation 
of  the  prolapsed  fibroid  may  occur,  resulting  in  gangrene,  a  very 
serious  complication  (Fig.  1125).    Fibrous  polypi  are  less  serious  than 


FIBROIDS  OF   THE   UTERUS 


1163 


larger  myomatous  submucous  tumors,  rarely  causing  alarming  bleed- 
ing. Yet  the  presence  of  any  submucous  growth  predisposes  to  infec- 
tion of  the  endometrium,  and  this  readily  extends  to  the  tubes,  so  that 
hydrosalpinx,  as  already  noted  (p.  1134),  is  a  frequent  complication, 
Or  infection  may  spread  directly  to  the  tumor  mass,  causing  a  very 
serious  form  of  septic  metritis. 


Fig.  1125. — Prolapse  of  submucous  fibroid  (strangulated)  with  complete  inversion 
of  vagina — uterus  not  inverted.  Age  forty-three  years.  Had  normal  childbirth  two 
years  ago,  and  no  symptoms  from  fibroid  until  prolapse  occurred,  twenty-three  hours 
before  operation  (vaginal  hysterectomy).  Death  from  peritonitis  five  days  after 
operation.    Episcopal  Hospital. 

Diagnosis. — This  is  made  from  attention  to  the  history  of  the  case, 
from  observation  of  the  symptoms,  and,  most  important  of  all,  from 
the  physical  examination.  It  is  especially  important  in  every  case 
to  exclude  the  presence  of  pregnancy:  a  large  interstitial  myoma,  par- 
ticularly if  softened  as  the  result  of  passive  congestion  with  edema, 
may  so  closely  simulate  pregnancy  as  to  deceive  even  the  elect.  Too 
much  reliance  should  not  be  placed  on  the  history  in  such  cases,  if 
it  is  impossible  to  corroborate  the  patient's  tale;  many  women  would 
be  pleased  to  be  relieved  of  a  pregnancy  by  hysterectomy,  and  are 
wilfully  deceitful.  Usually,  however,  in  pregnancy  the  cervix  is  softer, 
the  uterus  feels  more  cystic,  the  menses  are  absent,  and  always  (if 
the  policy  of  "waiting  and  watching"  is  followed)  indisputable  signs 
of  pregnancy  will  declare  themselves  in  time.  An  ovarian  cyst  may 
closely  resemble  a  fibroid  of  the  uterus  if  it  is  very  tense,  and  particu- 
larly if  intraligamentary;  in  some  cases  nothing  short  of  an  exploratory 
operation  will  clear  the  diagnosis.  In  the  case  of  pyosalpin.v  the  history 
is  different;  the  mass  usually  is  posterior  to  the  uterus  and  fixed;  there 
is  more  leucorrhea  than  in  fibroids,  and  menstruation  is  irregular 
rather  than  prolonged  or  profuse.  The  diagnosis  from  carcinoma 
and  other  malignant  tumors  rarely  is  difficult. 

Adenomyoma  of  the  uterus  occurs  in  5  per  cent,  or  more  of  cases. 
The  glandular  elements  are  derived  either  from  the  endometrium 
(Cullen,  1903),  or  from  remnants  of  the  Wolffian  body  in  the  walls 


11G4  SURGERY  OF   THE  FEMALE  GENITALS 

of  the  uterus  (von  Recklinghausen,  1896).  The  tumors  frequently 
are  infiltrating  in  character,  but  occasionally  more  or  less  encapsu- 
lated subperitoneal  growths  develop,  or  even  polypi.  Cyst  formation 
is  the  only  form  of  degeneration  which  is  common.  The  symptoms 
are  much  the  same  as  in  cases  of  ordinary  fibroids,  and  the  diagnosis 
seldom  is  made  except  in  the  pathological  laboratory.  The  existence 
of  this  variety  of  myoma  may  be  suspected,  however,  if  the  tumor 
is  very  adherent,  and  particularly  if  it  is  cystic  and  the  contents  of 
the  cysts  are  chocolate  colored  (menstrual  Hind).  The  proper  treat- 
ment is  hysterectomy. 

Prognosis. — The  prognosis  of  uterine  fibroids  is  not  good.  Until 
some  symptoms  are  produced,  the  growths  often  pass  undiscovered. 
But,  when  symptoms  of  any  kind  once  have  appeared,  it  is  rare  for 
the  patient  ever  again  to  be  free  from  discomfort.  The  menopause 
is  indefinitely  deferred,  and  the  tumor  usually  continues  to  grow. 
Not  to  mention  various  degenerations  (calcareous,  myxomatous, 
cystic,  hyaline,  malignant)  of  the  tumors,  which  occur  in  about  20 
per  cent,  of  cases,  and  the  ever-threatening  degeneration  of  the 
cardiac  muscle,  which  is  almost  inevitable,  the  woman  is  subject 
to  the  dangers  of  hemorrhage,  miscarriage,  sepsis,  inversion  of  the 
uterus,  etc. 

Treatment  of  Uterine  Fibroids. — We  hear  reports  lately  of  favorable 
results  secured  by  a;-rays  and  radium  treatment,  just  as  some  years  ago 
much  was  heard  of  the  electric  treatment  advocated  by  Apostoli,  and 
even  before  that  time  of  the  curative  value  of  ergot.  Whether  these 
new  departures  will  prove  more  lasting  than  their  predecessors  time 
alone  can  show;  but  for  the  present  and  immediate  future  at  least,  the 
treatment  advised  and  practised  by  rational  surgeons  is  operative.1 
The  tumors  should  be  removed.  In  some  comparatively  young  women 
who  are  anxious  to  bear  children,  it  may  be  justifiable  to  remove  the 
individual  tumors,  leaving  the  main  bulk  of  the  uterus  intact.  This 
is  especially  the  case  when  a  polypus  is  present,  without  other  demon- 
strable growths.  Polypi  may  be  removed  through  the  vagina  after 
the  division  of  the  pedicle  by  scissors  or  by  formal  excision  from  the 
uterine  wall.  Temporary  division  of  the  cervix  may  be  necessary. 
Bleeding  from  the  stump  of  the  polyp  rarely  is  severe  and  may  be 
controlled  by  packing  if  suture  is  impossible.  Isolated  subperitoneal 
growths  may  be  removed  by  excision  and  enucleation  through  an 
abdominal  wound;  the  operation  is  known  as  myomectomy.  The  objec- 
tions to  it  (largely  theoretical)  are  that  other  tumors  almost  surely 
are  overlooked  and  will  subsequently  give  rise  to  trouble;  that  even 
should  pregnancy  follow  it  is  very  apt  to  be  terminated  prematurely; 
and  that  should  pregnancy  continue  to  term,  grave  complications 
may  arise  during  parturition  or  the  puerperium  from  other  fibroids 
which  have  grown  during  the  pregnancy.  But  in  a  small  proportion 
of  cases,  carefully  selected,  the  operation  is  of  value. 

1  G.  E.  Shoemaker  (1915)  reported  a  case  of  sarcomatous  transformation  five 
years  after  bleeding  was  checked  by  x-ray  treatment. 


HYSTERECTOMY 


116£ 


In  the  great  majority  of  cases  removal  of  the  uterus  {hysterectomy) 
is  preferable.  This  may  be  accomplished  by  the  vaginal  route  (vaginal 
hysterectomy)  if  the  uterus  is  small;  but  in  most  cases  the  abdominal 
operation  is  required.  If  the  uterus  is  amputated  above  the  cervix 
the  operation  is  known  as  supravaginal  hysterectomy;  if  the  cervix  also 
is  removed  the  proper  term  is  pan-hysterectomy .  In  most  cases  the 
tubes  and  ovaries  are  removed  also  (complete  supravaginal  or  pan- 
hysterectomy) . 


Fig.  1126. — Diagram  to  show  technique  of  abdominal  panhysterectomy:  on  the 
right  of  the  picture  the  left  ovary  and  tube  are  being  removed  with  the  uterus;  the 
right  ovary  is  not  being  removed.  Ligatures  have  been  placed  on  the  ovarian  and 
uterine  arteries  and  on  the  round  ligaments  on  both  sides,  and  the  tissues  close  to  the 
uterus  have  been  clamped.     The  anterior  vaginal  fornix  has  been  opened  exposing  the 


Abdominal  Hysterectomy. — The  fundus  of  the  uterus  is  drawn  through 
the  abdominal  wound  by  volsellum  forceps,  and  one  broad  ligament 
is  exposed  by  drawing  the  tumor  well  to  the  other  side.  Clamps 
may  then  be  applied  to  both  sides  of  the  proposed  section,  leaving 
the  adnexa  attached  to  the  uterus  if  they  are  diseased  (Fig.  1126). 
In  many  cases  it  is  simpler  to  ligate  the  ovarian  vessels  at  once, 
applying  clamps  only  to  the  uterine  side  of  the  broad  ^  ligament. 
Hemorrhage  being  thus  controlled,  the  broad  ligament  is  divided 
with  scissors  down  to  the  level  of  the  cervix,  but  not  far  enough  to 
wound  the  uterine  artery,  which  has  not  yet  been  secured.  The  round 
ligament  is  then  ligated  close  to  the  uterus,  and  divided  between  the 
ligature  and  uterus.  The  tumor  is  then  pulled  to  the  patient's  other 
side,  and  the  broad  and  round  ligaments  are  divided  as  on  the  first  side. 


HOG  SURGERY  OF   THE   FEMALE  GENITALS 

This  frees  the  uterus  so  that  in  most  cases  the  cervix  can  be  drawn 
up  into  the  abdominal  wound.  The  tumor  is  then  turned  backward, 
and  an  incision  is  made  from  one  round  Ligament  to  the  other  some- 
what above  the  vesical  reflection  of  peritoneum.  The  peritoneal  flap 
thus  formed  is  pushed  away  from  the  cervix  by  gauze  dissection, 
until  at  the  sides  of  the  cervix  the  uterine  vessels  are  exposed.  These 
arc  clamped  close  to  the  uterus  and  ligated  not  more  than  1  cm. 
distant;  the  ureter  crosses  under  the  uterine  artery  about  2  cm. 
distant  from  the  cervix.  The  uterine  vessels  are  then  divided  on 
both  sides,  between  clamp  and  ligature.  The  uterus  is  then  turned 
well  forward  over  the  pubes,  and  an  incision  is  made  across  its 
body  above  the  pouch  of  Douglas,  from  one  broad  ligament  attach- 
ment to  the  other;  and  the  peritoneal  flap  thus  formed  is  pushed 
downward  by  gauze  dissection.  Finally  the  cervix  is  cut  through 
with  scissors  in  funnel  shape,  and  the  uterus  is  removed.  The 
cervical  canal  is  then  closed  with  catgut  sutures,  and  the  stumps 
of  the  round  and  broad  ligaments  are  sutured  to  it,  so  as  to  support 
it  in  proper  position.  Then  the  peritoneal  flaps  front  and  back  are 
united  over  the  cervical  stump,  closing  in  all  areas  denuded  of  peri- 
toneum.   In  most  cases  the  abdomen  is  closed  without  drainage. 

If  it  is  desired  to  remove  the  cervix  also,  the  dissection  must  be  carried 
a  little  deeper;  then  the  vaginal  vault  is  divided.  The  surgeon  must 
look  for  bleeding  from  the  vaginal  arteries  and  secure  a  dry  field 
before  proceeding.  Finally,  the  stumps  of  the  round  and  broad 
ligaments  are  implanted  into  the  vaginal  vault.  Though  removal  of 
the  cervix  prolongs  the  operation  somewhat,  I  believe  it  should  always 
be  done  in  the  absence  of  distinct  contra-indications. 

Vaginal  Hysterectomy. — -This  is  suitable  only  in  cases  where  the 
tumor  is  small,  and  the  vagina  sufficiently  relaxed.  A  self-retaining 
speculum  is  used  (Fig.  1095),  and  the  cervix  is  closed  by  sutures  or 
by  a  double  tenaculum  forceps,  and  drawn  outside  the  vulva.  An 
incision  is  next  made  all  around  the  cervix,  through  the  mucosa; 
the  incision  in  the  anterior  cul-de-sac  is  deepened,  pushing  the 
bladder  wall  and  with  it  the  ureters  well  upward  and  forward, 
until  the  peritoneal  cavity  is  opened.  A  finger  is  then  inserted 
into  the  pelvic  cavity  and  passed  behind  the  cervix,  and  on  this 
finger  as  a  guide  the  posterior  vaginal  cul-de-sac  is  further  incised 
until  the  peritoneal  pouch  of  Douglas  is  opened.  Gauze  is  then 
packed  into  this  opening  to  keep  the  intestines  from  prolapsing 
into  the  w^ound.  Any  bleeding  is  easily  controlled  by  hemostats. 
If  the  tumor  is  not  too  large,  the  fundus  of  the  uterus  may  now  be 
hooked  down  by  the  finger  and  brought  out  through  the  incision  in  the 
anterior  vaginal  cul-de-sac.  If  this  can  be  accomplished  the  broad 
ligaments  may  then  be  ligated  from  their  ovarian  border  dowmwrard 
to  the  cervix,  as  in  supravaginal  hysterectomy.  If  the  fundus  of  the 
uterus  cannot  be  delivered  in  this  way,  the  broad  ligaments  are 
clamped  from  belowr  upward,  not  more  than  1  cm.  distant  from  the 
cervix,  removing  the  tubes  and  ovaries  also  if  they  are  diseased  (Fig. 


CARCINOMA  OF  THE  UTERUS 


1167 


1127).  The  broad  ligaments  are  then  cut  through  between  the  clamps 
and  the  uterus;  and  the  peritoneum  is  closed,  the  gauze  pack  being 
removed  as  the  last  peritoneal  suture  is  tied.  After  carefully  ligating 
the  broad  ligaments,  their  stumps  are  sutured  to  the  vaginal  vault. 
A  gauze  drain  is  left  in  the  vagina.  The  operation  may  be  done  also 
without  ligatures,  leaving  the  clamps  on  the  broad  ligaments  for  several 
days.  Special  clamps,  with  detachable  handles,  have  been  devised 
for  this  purpose. 


Fig.  1127. — Diagram  of  vaginal  hysterectomy,  showing  application  of  clamps 
to  the  broad  ligaments. 

Carcinoma  of  the  Uterus. — This  is  exceedingly  common,  especially 
in  the  cervix.  Only  about  5  to*10  per  cent,  of  cases  occur  in  the  body 
of  the  uterus.  In  the  cervix  the  growth  almost  always  is  a  squamous- 
celled  epithelioma,  though  carcinoma  of  the  glandular  type  (adeno- 
carcinoma) sometimes  occurs;  while  in  the  body  of  the  uterus  the 
tumor,  with  a  very  few  rare  exceptions,  is  an  adenocarcinoma.  Most 
patients  are  in  the  fourth  decade  of  life,  approaching  or  past  the  meno- 
pause ;  almost  all  have  borne  children,  and  many  have  had  lacerations 
of  the  cervix  which  have  not  received  proper  treatment. 

Carcinoma  of  the  Cervix  occurs  in  two  forms:  (1)  as  an  everting,  vege- 
tating, proliferating,  or  cauliflower-like  growth;  or  (2)  as  an  inverting, 
infiltrating,  and  contracting  growth.  At  an  early  stage  of  the  disease 
these  two  types  are  quite  distinct,  but  later  the  carcinomatous  tissue 
tends  to  become  necrotic,  and  when  sloughs  have  been  shed  the  cervix 
is  represented  only  by  a  crater-like  cavity  filled  with  purulent  debris 
(Fig.  1124).  The  everting  type  is  more  easily  recognized  at  an  early 
date,  owing  to  the  papillary  excrescences  which  form;  whereas  in  the 
infiltrating  type  very  extensive  invasion  of  the  cervical  tissues  may 
occur  before  there  is  much  alteration  in  the  appearance  of  its  vaginal 
surface. 

Extension  occurs  to  all  surrounding  tissues,  but  in  no  definite  order. 
The  bases  of  the  broad  ligaments  frequently  are  invaded  early,  so 
that  the  uterus  becomes  fixed;  the  ureters  are  surrounded  and  may 


1168  SlliCKRY  OF   THE   FEMALE  GENITALS 

become  compressed  by  the  growth;  the  pelvic  lymphatics  up  to  and 
even  beyond  the  bifurcation  of  the  aorta  are  invaded;  sometimes  exten- 
sion to  the  inguinal  lymphatics  occurs;  the  growth  extends  locally 
into  the  vaginal  vault,  and  the  bladder  and  even  the  rectum  may  be 
infiltrated,  so  that  late  in  the  disease  distressing  vesicovaginal  fistula? 
(rarely  rectovaginal)  may  form.  In  most  cases  the  uterine  body 
remains  free  of  disease,  the  carcinomatous  growth  rarely  extending 
above  the  level  of  the  internal  os. 

Symptoms. — These  usually  are  absent  or  are  overlooked  until  the 
disease  is  quite  far  advanced;  only  from  10  to  20  per  cent,  of  patients 
applying  for  treatment  are  susceptible  of  cure.  The  most  important 
symptom,  and  usually  the  earliest,  is  bleeding,  especially  intermenstrual 
or  occurring  after  the  menopause.  Usually  this  bleeding  occurs  spon- 
taneously, and  is  moderate  or  apparently  insignificant  in  amount; 
it  may  follow  coitus  or  defecation;  occasionally  it  is  profuse  and  pros- 
trating. Such  a  sudden  and  alarming  hemorrhage  almost  always  is 
due  to  carcinoma  and  not  to  fibroids.  The  bleeding  is  painless  as  a 
rule,  and  unless  the  woman  notes  its  occurrence  and  submits  to  vaginal 
examination,  she  may  go  along  for  months  before  anything  further 
occurs  to  call  attention  to  her  condition.  There  may  be,  indeed 
there  usually  is,  a  certain  amount  of  leucorrhea;  and  the  serous,  watery, 
or  blood-stained  character  of  this,  and  at  a  later  period  its  fetor,  may 
arrest  her  attention.  Pain  is  a  late  and  unimportant  symptom;  it 
rarely  is  severe  until  the  sacral  plexus  is  involved  and  the  tumor 
entirely  inoperable. 

The  disease  may  thus  be  divided  clinically  into  three  stages:  (1)  the 
stage  of  occasional  hemorrhage;  (2)  the  stage  of  gradual  decline  of  health, 
with  fetid  leucorrhea;  and  (3)  the  inoperable,  hopeless  stage,  with  excru- 
ciating pain,  and  disgusting  odor,  the  patient's  condition  being  loath- 
some to  herself  and  all  about  her.  The  average  duration  of  the  disease 
from  first  symptoms  to  death  averages  from  fifteen  to  twenty  months. 

Carcinoma  of  the  body  of  the  uterus  presents  the  same  symptoms, 
but  they  develop  at  a  much  later  period,  and  are  not  attended  by  any 
definite  physical  signs,  except  slight  enlargement  of  the  uterus.  It  is 
much  more  frequent  in  women  who  have  borne  no  children  than 
carcinoma  of  the  cervix. 

Diagnosis. — Every  woman  whose  symptoms  suggest  the  mere  pos- 
sibility of  the  disease  should  be  submitted  to  a  competent  surgeon 
for  a  most  painstaking  vaginal  examination;  any  alteration  in  the 
cervix,  especially  if  bleeding  is  easily  aroused,  should  be  regarded  as 
suspicious,  and  a  section  should  be  taken  for  microscopic  study. 
This  is  easily  done  after  swabbing  the  cervix  inside  and  out  with  10 
per  cent,  eucain  solution;  the  section  (removed  with  knife  or  scissors) 
should  extend  from  the  cervical  canal  into  apparently  healthy  tissue, 
and  should  be  submitted  to  a  pathologist  for  prompt  report.  If  a 
carcinoma  of  the  uterine  body  is  suspected,  the  curette  should  be 
used,  and  the  scrapings  mounted  and  examined  histologically. 

Treatment. — A  radical  operation,  similar  in  scope  to  that  practised 
in  cases  of  carcinoma  of  the  breast,  and  involving  removal  of  the  pelvic 


CHORIO-EPITHELIOMA   MALIGNUM  1169 

lymph  nodes  and  connective  tissues  in  one  mass  with  the  diseased 
uterus,  was  systematized  in  1895  by  Ries,  elaborated  by  Sampson, 
and  popularized  by  Mackenrodt,  Wertheim,  and  others;  but  while 
in  theory  this  procedure  is  correct,  it  is  found  that  the  immediate 
mortality  even  in  the  hands  of  skilled  gynecological  operators  is  about 
25  per  cent.1  An  inexperienced  surgeon  will  not  be  able  to  do  a  com- 
plete operation,  and  in  his  attempt  to  be  ultra-radical  probably  will 
do  more  harm  than  good.  Many  investigators  claim  that  a  truly 
radical  operation  is  impossible,  and  point  out  that  autopsies  have 
shown  that  whenever  carcinomatous  lymph  nodes  were  removed  at 
operation,  others  were  overlooked.  It  seems  to  me  that  we  must 
look  upon  these  radical  methods  as  still  upon  trial,  and  only  to  be 
attempted  by  exceptionally  skilled  and  experienced  operators  in 
carefully  selected  cases.  When  the  uterus  is  not  fixed  its  removal  by 
the  ordinary  method  of  pan-hysterectomy  (p.  1165),  paying  special 
attention  to  wide  excision  of  the  vaginal  vault,  but  without  attempts 
to  dissect  the  pelvic  lymph  nodes,  is  an  operation  not  attended  by  an 
unjustifiable  primary  mortality;  and  many  patients  so  treated  will 
be  restored  temporarily  to  health  and  enjoyment  of  life;  and  when 
recurrence  or  metastasis  takes  place,  as  it  almost  surely  will,  the 
condition  will  be  much  less  distressing  than  if  no  operation  had 
been  performed. 

High  amputation  of  the  cervix  by  the  electrocautery  knife,  may  be 
used  as  a  preliminary  to  dispose  of  the  sloughing  vaginal  mass,  the 
abdominal  hysterectomy  being  postponed  for  ten  days  or  two  weeks. 

When  the  uterus  is  fixed,  and  its  removal  appears  impossible,  the 
patient's  comfort  may  be  greatly  promoted  and  her  life  prolonged 
by  cauterizing  the  growth  thoroughly  with  the  actual  cautery.  This 
palliative  operation  may  be  repeated  every  few  months,  and  may  be  used 
in  cases  of  recurrence  after  hysterectomy.  It  deserves  to  be  employed 
with  more  enthusiasm  than  is  usually  accorded  to  palliative  operations.2 

Chorio-epithelioma,  or  Deciduoma  Malignum  (Sanger,  1888),  is 
an  exceedingly  malignant  tumor  growing  in  the  body  of  the  uterus 
after  pregnancy.  The  pregnancy  frequently  is  terminated  before 
term,  and  the  most  favorable  cases  are  those  in  which  the  diagnosis 
is  made  by  the  pathologist  from  examination  of  retained  tissues 
removed  in  such  cases  (Fig.  1128).  Such  examination  never  should  be 
neglected.  The  tumor  probably  arises  from  the  chorionic  and  not 
from  the  decidual  tissues;  it  behaves  like  the  most  malignant  types 
of  sarcoma,  giving  early  venous  metastasis,  especially  to  the  lungs 
(78  per  cent.)  and  vagina  (54  per  cent.)  (Dorland).  Vaginal  growths 
may  be  the  only  evidences  of  the  disease.  The  chief  symptoms  resemble 
those  of  uterine  carcinoma,  namely  bleeding,  and  watery  leucorrhea. 

1  Though  Cobb  (1920)  reports  a  mortality  of  11.6  per  cent,  in  60  cases,  with  20 
out  of  50  patients  free  from  recurrence  after  five  years. 

2  Systematic  cauterization  of  cervical  carcinomata  was  introduced  by  Byrne 
(1896),  and  has  been  revived  by  Percy  (1914),  who  claims  that  the  use  of  low 
grades  of  heat  for  prolonged  periods  (made  possible  by  a  water-cooled  speculum) 
kills  the  carcinoma  cells  without  destroying  normal  tissues.  His  views  are  not 
shared  by  most  surgeons. 

74 


1170 


SURGERY  OF  THE  FEMALE  CENITALS 


The  proper  treatment  is  pan-hysterectomy,  if  the  diagnosis  is  made 
before  distant  metastases  occur.  Removal  of  vaginal  growths  in 
cases  where  the  uterus  appears  free  from  the  disease,  has  occasionally 
proved  successful. 


■  ^.   ., 


v 


■ 


Fig.  1128. — Chorio-epithelioma  in  a  patient  aged  forty-two  years.  Diagnosis  made 
from  microscopical  examination  of  scrapings  from  endometrium  ten  days  after  an 
abortion.     Immediate  hysterectomy.     No  recurrence  after  six  years. 


Fig.  1129. 


-Carcinoma  of  vulva;  age  forty-five  years;  duration  eight  months. 
Pennsylvania  Hospital. 


Carcinoma  of  the  Vulva  is  not  very  rare  (Fig.  1129).  Extension 
occurs  to  the  inguinal  lymph  nodes,  and  radical  operation  requires 
the  extirpation  of  these  on  both  sides,  the  technique  being  similar 
to  that  adopted  in  cases  of  carcinoma  of  the  external  genitals  of  the 
male. 


INDEX. 


Abdomen,  distention,  859 

gunshot  wounds,  211,  897 

treatment,  845 
injuries,  891 

operation,  894 
operations,  869 
pendulous,  953 
stab  wounds,  896 
Abdominal  incisions,  870 

operation,  after-treatment,  876 

preparation  of  patient,  875 

technique,  874 
section,  869 
tumors,  diagnosis,  1007 
wall,  contusion,  891 

rigidity,  857 

rupture,  891 
woimd,  suture,  881 
Ablation  of  breast,  770 
Abortion,  tubal,  1148 
Abrasions,  159 
Abscess,  26,  46 
acute,  46 

diagnosis,  48 

dressing,  51 

pathology,  46 

treatment,  49 
drainage,  50 
Hilton's  method,  50 
alveolar,  707 
appendicular,  910 
axillary,  777 
Bezokl's  679 
bone,  479 
brain,  624 
breast,  750 
Brodie's,  479 
chronic,  46 
cold,  46,  77,  519 

treatment,  526 
digital,  311 
gluteal,  653 
iliac,  864 

traumatic,  892 
ischiorectal,  958 
liver,  991 
lumbar,  653,  864 
lung,  799 
mammary,  750 
metastatic,  71 
neck,  724 


Abscess,  ovary,  1135 

palmar,  313 

pancreas,  1001 

parosteal,  469 

pelvic,  864,  1153 

extraperitoneal  incision,  1096 
vaginal  puncture,  1154 

pelvi-rectal,  958 

peri-anal,  958 

perinephric,  1031 

peritonsillar,  713 

peri-urethral,  1082 

phlegmonous,  46 

pointing,  47 

post-Ochsner,  912 

prostate,  1083 

psoas,  653 

residual,  856 

peritoneal,  864 

retropharyngeal,  652 

retrorectal,  958 

scrofulous,  46 

spinal,  652 

diagnosis,  653 

spleen,  1009 

subcranial,  623 

submammary,  751 

submucous,  958 

subpectoral,  778 

subphrenic,  865 

subscapular,  779 

suprascapular,  780 

tongue,  695 

tubo-ovarian,  1134 

vulvo-vaginal,  1128 
Acapnia,  182 

Acetabular  rim,  fracture,  361 
Achillodynia,  298 
Achondroplasia,  455 
Acid  burns,  178 
Acidosis,  188 
Acne  rosacea,  667 
Acromegaly,  467 

Acromioclavicular  dislocation,  430 
Actinomycosis,  82 
Acupressure,  261 
Acupuncture,  144 
Adamantinoma,  112 
Adenitis,  299 

cervical,  723 
Adenocarcinoma,  126 

breast,  763 
Adenoma,  120 

(1171) 


1172 


INDEX 


Adenoma  of  breast,  762 

of  rectum,  '.Mis 
Adenosarcoma,  100 
Adherent  prepuce,  I L02 
Adhesions,  peritoneal,  805 
Adhesive  glue,  204 

Agnew's  operation,  webbed  fingers,  549 
Ainhum,  63 
Air-hunger,  259 

Air  passages,  foreign  bodies,  715 
operations,  718 
surgery,  715 

sinuses,  operations,  705 
Albee's  bone  saw,  248 

operation,  059 
Albert-Lemberl  suture,  881 
Albert's  disease,  298 
Alexander's  operation,  1143 
Alexins,  23 

Alimentary  glycosuria,  1003 
Allis's  sign,  400 
Alveolar  abscess,  707 
Alveolus,  periostitis,  710 

tumors,  710 
Ambulance  chirurgieal  automobile,  191 
Amebic  dysentery,  950 
Amputating  knives,  215 
Amputations,  212 

ankle-joint,  231 

arm,  227 

Ashhurst's,  232 

Berger's,  230 

Bier's  osteoplastic,  222 

Billroth's,  235 

Brashear's,  234 

breast,  759 

cervix,  1139,  1109 

Chopart's,  231 

cinematoplastic,  250 

circular  method,  218 

conditions  requiring,  212 

Dieffenbach's,  234 

dressing,  216 

Dupuytren's,  228 

Einschnitt,  217 

elbow,  227 

elliptical  method,  220 

fingers,  224 

flap  method,  220 

foot,  230 

forearm,  226 

Fourneaux-Jordan's,  234 

in  gangrene,  60 

Gritti's,  233 

guillotine,  217 

Guthrie's,  234 

Hancock's,  231 

hand,  224 

Hey's,  230 

hip-joint,  233 

instruments,  212 

interilioabdominal,  235 

intermediate,  223 

interscapulo-thoracic,  230 

knee-joint,  232 

Larrey's  227,  234 


Amputations,  Lee's,  232 

leg,  232 

Lisfranc's,  230 

medio-tarsal,  230 

metacarpal,  226 

methods,  217 

modified  circular  method,  220 

mortality,  223 

multiple,  220 

neuroma,  326 

operative  procedure,  215 

oval  method,  220 

penis,  1106 

phalanges,  230 

Pirogoff's,  231 

"poor  man's,"  225 

primary,  223 

racket  method,  220 

"rich  man's,"  225 

en  saucisse,  217 

secondary,  223 

Sddillot's,  704 

Senn's,  235 

shoulder-joint,  227 

Skey's,  230 

special,  224 

Spence's,  227 

spontaneous,  59 

Stokes's,  233 

subastragalar,  231 

supracondylar,  233 

Syme's,  231 

Teale's,  232 

Textor's,  231 

thigh,  233 

thumb,  226 

transcondylar,  233 

traumatic,  212 

wrist-joint,  226 
Anaplasty,  236 
Anastomosis,  intestinal,  884 
end-to-end,  884 
lateral,  886 
Murphy  button,  890 
Anatomical  tubercle,  74 
Anemia,  splenic,  1010 
Anesthesia,  149 

accidents,  152 

chloroform,  153 

ether,  150 

ethyl  chloride,  153 

freezing,  157 

general,  150 

administration,  154 
choice,  154 

infiltration,  158 

intratracheal  insufflation,  155 

local,  157 

nitrous  oxide,  153 

primary,  151 

spinal,  158 
Anesthetics,  149 
Aneurysm,  278 

by  anastomosis,  278 

Anel's  ligation,  285 

arterio-venous,  207 


INDEX 


1173 


Aneurysm,  bone,  487 

Brasdor's  ligation,  286 

causes,  287 

cirsoid,  278 

classification,  249 

dissecting,  2S0 

extirpation  of  sac,  288 

false,  279 

filipuncture,  287 

fusiform,  280 

Hunter's  ligation,  285 

ligation,  285 

Matas's  operation,  288 

needle,  164 

racemose,  278 

saccular,  280 

traumatic,  265,  278 

treatment,  284 

non-operative,  284 
operative,  285 

true,  279 

tubular,  280 

varicose,  267 

venous,  265 

Wardrop's  ligation,  286 

wiring,  287 
Aneurysmal  bruit,  283 

varix,  267 
Aneurysmoplasty,  288 
Angeioleucitis,  299 

Angeioma   of   breast,    762.     See   Hem- 
angeioma. 

cavernous,  277 
Angeiotripsy,  261 
Angina  Ludovici,  693 
Ankle,  arthroplasty,  256 

dislocation,  451 

fractures,  416 

sprained,  421 

tuberculosis,  542 
Ankle-joint  amputation,  231 
Ankylosis,  508 

temporo-maxillary  joint,  709 
Anoci-association,  149 
Anteflexion  of  uterus,  1143 
Ante  version  of  uterus,  1143 
Anthrax,  85 
Antisepsis,  36,  141 
Antiseptic  methods,  143 
Antiseptics,  36 
Antitoxic  sera,  44 
Antitoxins,  23 
Antrum,  maxillary,  706 
Antyllus,  operation  of,  287 
Anuria,  calculous,  1036 
Anus,  carcinoma,  968 

examination,  955 

false,  947 

formation  of,  969 

fissure,  960 

imperforate,  956 

surgery,  955 
Apoplexy,  621 
Appendicitis,  900 

acute,  903 

complications,  909 


Appendicitis,  acute,  operation,  906 
treatment,  906 

causes,  902 

chronic,  901,  915 

gangrenous,  913 

leukocytosis,  904 

obliterans,  901 

pathogenesis,  900 

simple  phlegmonous,  901 

ulcerative,  901 
Appendicostomy,  950 
Appendicular  abscess,  910 
Appendix,  carcinoma,  915 

coprolith,  902 

cyst,  902 

empyema,  902 

foreign  bodies,  902 

gangrene,  901 

intussusception,  916 

necrosis,  901 

occlusion  of  lumen,  902 

operation,  incisions,  872 

removal,  907 

stricture,  902 

surgery,  900 

tuberculosis,  915 
Arrow-wounds,  174 
Arsphenamin,  1060 
Arterial  embolism,  273 

thrombosis,  273 

varix,  278 
Arteriectasis,  279 
Arteriorrhaphy,  266 
Arteriovenous  wounds,  267 
Artery,  ligation,  262 

middle  meningeal,  613 
Arthrectomv,  529 
Arthritis,  492 

acute,  of  infants,  464 
rheumatic,  473 

atrophic,  493 

deformans,  493 

gelatinous,  520 

gonococcic,  514 

hypertrophic,  497 

metastatic,  515 

nodosa,  493 

rheumatic,  516 

senile,  498 

tuberculous,  519 

typhoid,  514 

villous,  503 
Arthrodesis,  570 
Arthrolvsis,  509 
Arthroplasty,  252 
Ascites,  995 
Asepsis,  36,  141 
Aseptic  fever,  68 

methods,  144 
Ashhurst's  amputation,  232 
Asphyxia,  traumatic,  776 
Aspiration,  149 
Astragalectomy,  565 
Astragalus,  dislocation,  452 

fracture,  419 
Atrophic  arthritis,  493 


1174 


INDEX 


At rophy,  bone,  l"> I 

prostate,  1097 
Auricle,  prominence  of,  677 

supernumerary,  077 
Autotransfusion,  '_'- 1 
Axillary  abscess,  777 

infusion,  140 
Azotorrhea,  1002 


B 


Bacillary  dysentery,  950 
Bacteria  in  inflammation,  18 
pathogenic,  18 
pyogenic,  28 
saprophytic,  19 
Bacteriemia,  08 
Bacteriolysins,  23 
Bacteriuria,  1019 
Balanitis,  1105 
Balano-posthitis,  1105 
Bandage,  elastic  webbing,  137 
figure-of-eight,  137 
flannel,  137 
gauze,  137 
many-tailed,  137 
muslin,  135 
plaster-of-Paris,  139 
recurrent,  137 
of  Scultetus,  137 
spica,  137 
spiral,  137 

reversed,  137 
T-,  139 
Bandaging,  135 
Banti's  disease,  1010 
Bartholin's  gland,  cyst  of,  1129 
Bartholinitis,  1127 
Barton's  fracture,  392 
Base  hospital,  192 
Basedow's  disease,  737 
Bassini's  operation,  839 
Battlefield,  diagram,  191 
Bayonet  wounds,  174 
Bazin's  disease,  295 
Beck's  bismuth  paste,  527 

operation,  1100 
Bed-sore,  61 

Bed-sores  in  spinal  injury,  045 
Bezold's  abscess,  079 
Bier's  hyperemia,  40 

osteoplastic  amputation,  222 
Bile-ducts,  carcinoma  of,  997 
operations,  984 
surgery,  974 
Biliary  calculus,  977 
colic,  975,  979 
fistula,  983 
sand,  977 
Billroth's  amputation,  235 
gastrectomy,  933 
powder,  178 
Birth  injuries,  1138 

shoulder,  550 
"Birth-mark,"  270 


Bismuth  paste,  527 
Bistoury,  48 
Bites,  174 

Bladder,  calculus  in,  1021 
carcinoma,  1021 
contracture,  1097 
diverticulum,  1019 
exstrophy,  1017 
foreign  bodies,  1020 
injuries,  1020 
irrigation,  1019 
papilloma,  1021 
rupture,  1020 
surgery,  1013 
tuberculosis,  1020 
tumors,  1021 
Blank  cartridge  wounds,  198 
Blastoma,  lOO 
Blastomatoid  growths,  107 
Blastomycosis,  84 
Blood,  transfusion,  147 
Blood-vascular  system,  diseases,  209 

surgery,  259 
Bloodvessels,  gunshot  wounds,  203 
subcutaneous  injuries,  265 
suture  of,  200 
wounds,  200 
Boas's  area,  979 
Boil,  291 
Bond  splint,  391 
Bone  abscess,  479 
aneurysm,  487 
atrophy,  454 
carcinoma,  491 
caries,  475 

congenital  absence,  540 
cysts,  403 
diseases,  454 
dystrophies,  454 
felon,  317 
fibromas,  487 
gunshot  wounds,  204 
hypertrophy,  400 
infections,  467 
inlay,  249 
necrosis,  474 
osteomyelitis,  468 
Paget's  disease,  463 
sarcoma,  487 
syphilis,  482 
transplant,  248 
tuberculosis,  479 
tumors,  485 
wax,  478 
Bottini  operation,  1091 
Bougie  k  boule,  1070 
Bougies,  1070 

filiform,  1070 
Bow-legs,  457 
Braces,  057 

Brachial  birth  palsy,  550 
Bradford  frame,  524 
Brain,  abscess,  624 
carcinoma,  626 
compression,  610 
concussion,  014 


INDEX 


1175 


Brain,  contusion,  614 
cysts,  626 
endothelioma,  626 
fibroma,  626 
glioma,  626 
sarcoma,  626 
surgical  affections,  612 
syphiloma,  626 
tuberculoma,  626 
tumor,  626 

decompression,  634 

resection  of  skull,  632 

treatment,  636 
Branchial  cysts,  731 

fistula,  731 
Branchiogenic  carcinoma,  731 
Brasdor's  ligation,  286 
Brashear's  amputation,  234 
Breast,  ablation  of,  770 

after-treatment,  773 
abnormal  involution,  756 
abscess,  750 
adenoma,  762 
adeno-sarcoma,  763 
amputation,  759 
angeioma,  762 
caked,  749 
cancer  cyst,  769 
carcinoma,  763 

cauterization,  774 

extension,  769 

inoperable,  774 

medullary,  768 

oophorectomy,  774 

operation,  770 

end-results,  778 
palliative,  774 

recurrence,  774 

scirrhous,  764 

simplex,  767 
congenital  anomalies,  748 
cystadenomatosis,  756 
cystic  disease,  756 
cystosarcoma  phyllodes,  761 
enchondroma,  762 
endothelioma,  762 
fibro-adenoma,  759 
fibro-adenomatosis,  755 
fibrocystadenoma,  761 
gumma,  753 
hydatid  disease,  761 
hypertrophy,  idiopathic,  755 
involution,  756 
irritable  tumor,  751 
lipoma,  762 
neuralgia,  751 
periductal  fibroma,  760 

myxoma,  760 
plastic  resection,  760 
proliferous  cysts,  761 
sarcoma,  762 
scirrhus,  764 

acute,  767 
senile  parenchymatous  hypertrophy, 

756 
surgery,  748 


Breast,  syphilis,  753 

tuberculosis,  753 

tumors,  754 

benign,  759 
cystadenomatous,  761 
malignant,  762 
periductal,  759 
Broad  ligament  cyst,  1157 
Brodie's  abscess,  479 
Bronchiectasis,  800 
Bronchoscopy,  716 
Bryant's  line,  400 
Bubo,  299 

chancroidal,  1061 

parotid,  672 

syphilitic,  1047 
Bubonocele,  831 
Buchanan  s  bone  inlay,  249 
Budin's  sign,  750 
Buerger's  disease,  58 
Bullet  wounds,  194 
Bunion,  290 
Buried  suture,  163 
Burns,  176 

acid,  178 

electric,  180 

mustard  gas,  178 

treatment,  177 

x-ray,  180 
Bursa,  wound,  297 
Bursitis,  298 

subdeltoid,  507 
Bursting  fractures,  603 
Button,  Murphy,  890 


Cachexia  thyreopriva,  737 
Caked  breast,  749 
Calcaneum,  fracture,  419 
Calcaneus,  paralytic,  568 
Calculous  anuria,  1036 
Calculus,  biliary,  977 

lacteal,  753 

pancreatic,  1004 

preputial,  1105 

renal,  1032 

salivary,  675 

ureteral,  1035 

vesical,  1021 
Callositas,  290 
Cailous  ulcer,  54 
Callus,  337 

Calmette's  serum,  176 
Cammidge  reaction,  1003 
Cancer,  mammary,  764 
Cancrum  oris,  63 
Cantwell's  operation,  1102 
Capillary  nevi,  276 
Caput  obstipum,  579 

succedaneum,  595 
Carbolic  acid  gangrene,  59 
Carbuncle,  292 

of  lip,  688 
Carcinoma,  121 


1176 


INDEX 


Carcinoma,  anus,  968 
appendix,  915 
bile-ducts,  997 

I  .ladder,  1021 

I e,  49  I 

brain,  026 
branchiogenic,  731 
breast,  763 

cauterization,  774 

extension,  796 

inoperable,  774 

medullary,  768 

oophorectomy,  774 

operation,  770 
palliative,  774 
radical,  end-results,  774 

recurrence,  774 
cecum,  949 
cervix,  1167 
cheek,  672 
columnar-celled,  126 
cylindrical-celled,  126 
duodenum,  928 
encephaloid,  127 
esophagus,  747 
gall-bladder,  997 
glandular,  126 
jaw,  710 
kidney,  1038 
larynx,  717 
liver,  996 
lymph  nodes,  304 
medullary,  127 
ovary,  1159 
pancreas,  1004 
penis,  1105 
prostate,  1097 
rectum,  968 

radical  operation,  970 
scirrhous,  126 
simplex,  127 
solid-celled,  127 
squamous-celied,  123 
stomach,  925 
thyroid,  741 
tongue,  697 
tonsil,  714 
treatment,  128 
uterus,  1167 
vulva, 1170 
Carcinomatous  mastitis,  768 
Cardiolysis,  269 
Cardiospasm,  746 
Caries,  bone,  475 

costal  cartilage,  780 
ribs,  780 
sicca,  519 
skull.  481 
Carotid  gland,  tumors,  729 
Carpus,  dislocation,  440 

fracture,  395 
Carrel  tubes,  170 
Carrel's  arteriorrhaphy,  266 
Carrel-Dakin  treatment,  170 

pleural  fistula,  797 
Carrying  angle,  383 


( iartilage  transplants,  247 

Castration,  1113 

<  'atarrhal  jaundice,  976 

Catheter,  1013 

Merrier,  1090 
Catheterism,  1089 
Catheterization,  ureters,  1016 
(  auterization,  144 
Cavernous  angeiomas,  277 
Cecostomy,  950 
Cecum,  carcinoma,  949 

mobile,  953 
Celiotomy,  869 
Cellulitis,  64 
Celluloid  jackets,  657 
Cephalic  pancreatectomy,  1005 
Cephalhematoma,  595 
Cephalocelc,  597 
Cerebellum,  tumor,  630 
Cerebral  palsies,  572 
Cerebritis,  624 
Cerumen,  impacted,  675 
Cervical  adenitis,  723 

ribs,  582 
Cervix,  amputation,  1139,  1169 

carcinoma,  1167 

laceration,  1138 

stenosis,  1126 
Chain  suture,  163 
Chancre,  81,  1045 

mixed,  1046 

of  tongue,  696 
Chancroid,  1060 

bubo,  1061 

treatment,  1063 
Charbon,  85 
Charcot's  intermittent  fever,  981 

joint,  497 
Chauffeur's  fracture,  392 
Cheek,  carcinoma,  672 

surgery,  669 
Cheloid,  109 
Chemotaxis,  negative,  21 

positive,  21 

injuries,  775 
Chest  wall,  surgery,  -775 
Chilblain,  180 
Chloroform,  153 
Chloroma,  114 
Cholangeitis,  976 
Cholecystectomy,  986 
Cholecystenterostomy,  989 
Cholecystoduodenostomy,  989 
Cholecystitis,  974 

calculous,  980 
Cholecystostomy,  985 
Cholecystotomy,  985 
Choledochenterostomy,  983 
Choledochostomy,  987 
Choledochotomy,  987 

retroduodenal,  988 

transduodenal,  989 
Cholelithiasis,  977 

simple,  979 

treatment,  981 
Cholemia,  981 


INDEX 


1177 


Cholesteatoma,  130 
Chondrectomy,  799 
Chondrodystrophia  fcetalis,  455 
Chondroma,  110 
Chondrosarcoma,  117 
Chopart's  amputation,  231 
Chordoma,  115 
Chorio-epithelioma,  1169 
Chromoureteroscopy,  1016 
Chylothorax,  299,  788 
Chylous  ascites,  299 
Cicatrization,  30,  52 
Cigarette  drain,  51 
Cinematoplastic  amputation,  256 
Circular  amputation,  218 
Circumcision,  1103 
Cirrhosis,  liver,  995 

stomach,  925 
Cirsoid  aneurysm,  278 
Citrate  method  of  transfusion,  147 
"Clacking  jaw, "428 
Clamp  and  cautery  for  hemorrhoids,  964 
Clap,  1065 
Clavicle,  dislocation,  429 

fracture,  363 
Clavus,  290 
Cleft  palate,  682 

operation,  685 
Cloacae,  469 
Cloquet's  hernia,  846 
Club  foot,  559 

hands,  559 
Coagulation,  electric,  705 
Coccygodynia,  362 
Coccyx,  fracture,  362 
Cock's  operation,  1Q80 
Coin-catcher,  742 
Cold  abscess,  77,  519 

effects  of,  178 
Coley's  fluid,  118 
Colic,  biliary,  979 

renal,  1034 
Colitis,  950 
Collapse,  183 
Colles's  fracture,  388 

law,  1053 
Colon,  surgery  of,  950 
Colostomy,  969 
Colpocele,  1139 
Colpo-perineorrhaphy,  1140 
Colporrhaphy,  1140 
Common  duct,  gall-stone,  981 

obstruction,  983 
Complement-fixation  test,  1057 
Compression  of  brain,  616 
Concussion  of  brain,  614 

of  spinal  cord,  639 
Condylomata  lata,  1050 
Congenital  absence  of  bone,  546 

contraction  of  fingers,  547 

dislocations,  547 
of  knee,  558 

hernia,  832 

talipes,  558 
Congestion,  20 
Constipation,  chronic,  954 


Contracture,  Dupuytren's,  585 

ischemic,  583 

muscles,  307 
Contused  wounds,  166 
Contusion,  159 

abdominal  wall,  891 

brain,  614 

scalp,  595 
Cooper's  hernia,  846 
Coprolith  in  appendix,  902 
Cord,  spinal.    See  Spinal  cord. 
Corn,  290 

Cornu  cutaneum,  291 
Corona  veneris,  1050 
Corpus  luteum  cyst,  1155 
Corset  liver,  990 
Costal  cartilage,  canes,  780 
Costo-transversectomy,  660 
Counter-irritation,  144 
Courvoisier's  law,  981 
Coxa  valga,  588 

vara,  457 
Coxalgia,  530 
Cranial  defects,  repair,  611 
Craniocerebral  topography,  612 
Cricothyrotomy,  719 
Critical  discharges,  32 
Crural  hernia,  845 
Crushed  limbs,  treatment,  224 
Crutch-palsy,  316 
Cryptogenous  joint  infection,  516 
Cryptorchidism,  1107 
Cubitus  valgus,  583 

varus,  583 
Cuneiform  tarsectomy,  564 
Curvature  of  spine,  573 
Cushing's  decompressive  operation,  634 

suture,  882 
Cut-throat,  722 
Cylindroma,  130 
Cyst  or  cysts,  130 

ante-natal,  132 

appendix.  902 

Bartholin's  gland,  1129 

bone,  463 

brain,  626 

branchial,  731 

broad  ligament,  1157 

cancer,  769 

corpus  luteum,  1155 

dentigerous,  711 

dermoid,  ovary,  1158 
scalp,  597 

extravasation,  131 

Graafian  follicle,  1155 

hydatid,  liver,  993 

kidney,  1038 

labial,  688 

fiver,  echinococcus,  993 

mesenteric,  949 

omental,  949 

ovarian,  1155 

ovary,  torsion,  1156 

pancreas,  1006 

parasitic,  132 

parovarian,  1156 


1178 


i\i)i:\ 


Cyst  or  cysts,  pilonidal,  297 

post-natal,  131 

proliferous  mammary,  761 

retention,  131 
ovary,  1 154 

sebaceous,  296 
of  scalp,  507 

sequestration,  131 

spleen,  1009 

thyro-glossal,  730 

tubo-ovarian,  1155 

urachal,  1017 
( lystadeno-carcinoma,  126 
( lystadenoma,  120 

breast,  756 

papilliferum,  120 
Cystadenomatosis  of  breast,  756 
Cystic  duct,  gall-stone,  980 
Cystitis,  1018 
Cystocele,  1139 
Cystoscope,  1015 
Cystotomy,  suprapubic,  1025 
Czerny's  suture,  881 


Dactylitis,  syphilitic,  483 

tuberculous,  481 
Dakin's  solution,  171 
Dance's  sign,  938 
Dangerous  area,  skull,  612 
"Dangle-foot,"  570 
Davis's  brace,  657 

incision,  872 

operation,  tarsus,  571 

reduction  of  hip,  551 
Death  after  operation,  185 
Deaver's  incision,  872 
Debridement,  201 
Decapsulation  of  kidney,  1028 
Deciduoma  malignum,  1169 
Decompressive  operation,  634 
Decortication  of  lung,  797 
Decubitus,  61 
Deformities,  congenital,  558 

paralytic,  565 
Deformity,  Sprengel's,  558 
Delirium,  traumatic,  183 

tremens,  184 
Demarquay's  operation,  1073 
Dentigerous  cyst,  711 
Dermatitis,  x-ray,  180 
Desmoids,  309 
Dessication,  electric,  705 
Diabetic  gangrene,  58 
Diapedesis,  20 
Diaphragm,  eventration,  803 

gunshot  wounds,  802 

hernia,  802 

rupture,  802 

stab  wounds,  801 

surgery,  801 
Dichloramin-T,  172 
Di dot's  operation,  549 
Dieffenbach's  operation,  234 


Dietl's  crises,  1027 
Digital  abscess,  311 
Digitus  malleus,  592 
Dilatation,  esophagus,  746 

stomach,  921 
Discission  of  pleura,  797 
I  >isinfection,  142 
Dislocated  kidney,  1027 

spleen,  1009 
Dislocations,  424 

acromio-clavicular,  430 

ankle,  451 

astragalus,  452 

carpus,  440 

clavicle,  429 

complete,  424 

complicated,  427 

compound,  427 

congenital,  424 

elbow,  436 

femur,  441 

hip,  441 

central,  361 
congenital,  547 

humerus,  430 

interphalangeal,  441 

knee,  445 

congenital,  558 

mandible,  428 

mediotarsal,  453 

metacarpus,  440 

metatarsus,  453 

Nelaton's,  452 

nerve,  316 

old,  427 

patella,  448 

pathological,  424 

phalanx,  toe,  453 
thumb,  440 

prognosis,  426 

radiocarpal,  440 

radius,  438 

recurrent,  428 

sacro-iliac,  441 

scapula,  430 

shoulder,  430 

congenital,  556 

simple,  424 

special,  428 

spinal  column,  640 

spontaneous,  424 

sternoclavicular,  429 

subastragalar,  453 

symptoms,  425 

tarsus,  452 

tendon,  310 

tibiotarsal,  451 

traumatic,  424 

treatment,  426 

ulna,  438 

wrist,  440 
Dissecting  aneurysm,  280 
Distention  of  abdomen,  859 
Diverticulitis,  sigmoid,  952 
Diverticulum,  bladder,  1019 

esophagus,  745 


INDEX 


1179 


Diverticulum,  Meckel's,  943 
Drainage,  50 

tube,  50 
Dressings,  fixed,  139 
removal,  141 

plaster-of-Paris,  139 

silicate  of  sodium,  141 

starch,  141 
Duct  cancer,  763 
Dudley's  operation,  1127 
Dugas's  sign,  432 
Duodenocholedochostomy,  989 
Duodenum,  carcinoma,  928 

gunshot  wounds,  898 

surgery,  916 

ulcer,  916 

chronic,  917 
hemorrhage,  920 
perforation,  919 
treatment,  918 
Dupuytren's  contracture,  585 

suture,  882 
Dysentery,  amebic,  950 

bacillary,  950 
Dystrophies,  bone,  454 

joints,  492 


E 


Ear,  foreign  bodies,  675 

furuncle,  676 

impacted  cerumen,  675 

surgery  of,  675 
Ear-ache,  678 
Eau  de  Javelle,  170 
Ecchondroma,  110 
Ecchymosis,  159 
Echinococcus  cyst,  fiver,  993 
Eck's  fistula,  996 
Ectopic  gestation,  1147 
Edebohls's  operation,  1028 
Edema  of  glottis,  717 
Edematous  ulcer,  53 
Elbow,  amputation,  227 

arthroplasty,  253 

dislocation,  436 

excision,  510 

fractures,  375 

subluxation,  439 

tuberculosis,  543 
Electric  burns,  180 
Electro-coagulation,  705 
Electro-dessication,  705 
Elephantiasis  Arabum,  302 

of  scrotum,  1119 
Embalming  solution,  Menciere's,  172 
Embolism,  269 

arterial,  273 

mesenteric,  943 

pulmonary,  273 

retrograde,  71 

septic,  70 
Embolus,  269 
Embryoma,  106 

ovary,  1158 


Emphysema,  pulmonary,  799 

surgical,  776 
Emphysematous  gangrene,  59 
Empyema,  appendix,  902 
articuli,  503 

gall-bladder,  975 

thoracis,  789 

bilateral,  796 
encapsulated,  795 
necessitatis,  790 
Encephalitis,  624 
Encephalocystocele,  597 
Enchondroma,  110 

breast,  762 
End-bearing  stumps,  222 
Endo-aneurysmorrhaphy,  288 
Endocervicitis,  1130 
Endometritis,  1130 
Endoscope,  1016 
Endosteoma,  111 
Endostosis,  111 
Endothelioma,  129 

brain,  626 

breast,  762 
End-to-end  anastomosis,  884 
Enostosis,  111 
Enterocele,  809 
Entero-epiplocele,  807 
Enterotomy,  941 

Epidemic  cerebrospinal  meningitis,  623 
Epididymitis,  1108 
Epididymo-orchitis,  1108 
Epididymo-  vasostomy,  1110 
Epigastric  hernia,  823 
Epilepsy,  focal,  636 

Jacksonian,  636 
Epiphyseal  separation,  329 
Epiplocele,  809 
Epiplopexy,  996 
Epispadias,  1101 
Epistaxis,  666 
Epithelioma,  123 

cheeks,  670 

deep-seated,  123 

lip,  688 

papillary,  124 

scalp,  597 

scrotum,  1119 

superficial,  124 
Epluchage,  200 
Epulis,  710 
Equino-varus,  congenital,  559 

paralytic,  566 
Erasion  of  joints,  529 
Erethistic  shock,  183 
Erysipelas,  65 

complications,  66 
Erythema  induratum,  295 

nodosum,  295 
Esmarch's  elastic  band,  213 
Esophagoscopy,  742 
Esophagotomy,  745 
Esophagus,  carcinoma,  747 

congenital  imperforation,  745 

dilatation,  746 

diverticulum,  745 


1180 


IXDKX 


Esophagus,  foreign  bodies,  742 

stricture,  7  1"> 

surgery,  742 
Esqiiillectomy,  205 
EstJander's  operation,  798 
Ether  anesthesia,  150 
Ethmoidal  disease,  705 
Ethyl  chloride,  153 
Eucain  anesthesia,  157 
Eusol,  170 

Evacuation  hospital,  190 
Eventration  of  diaphragm,  803 
Evidement,  478 
Excision,  elbow,  510 

hip,  539 

knee,  510 

shoulder,  513 

superior  maxilla,  712 

tumor,  132 

wrist,  513 
Exclusion  of  pylorus,  931 
Excoriation,  159 
Exophthalmic  goiter,  737 
Exostoses,  111 

cartilaginous,  485 

fibrous,  486 

subungual,  486 
Exstrophy  of  bladder,  1017 
Extirpation  of  penis,  1106 
Extradural  hemorrhage,  619 
Extra-uterine  pregnancy,  1147 


Facial  hemiatrophy,  710 
False  ankylosis,  508 

anus,  947 

formation,  969 
Farcy,  87 

Fascia  transplants,  246 
Fat  transplants,  246 

embolism,  188 
Fecal  fistula,  946 

impaction,  942 

incontinence,  965 
Felon,  311 

Female  genitals,  surgery  of,  1121 
Femoral  hernia,  845 

operation,  847 
rare  forms,  846 
Femur,  dislocation,  441 
reduction,  445 

fracture,  398 
Ferguson's  operation,  843 
Fergusson's  operation,  685 
Fever,  aseptic,  68 

surgical,  69 
Fibroadenoma,  120 
Fibroadenomatosis  of  breast,  755 
Fibrocystadenoma  of  breast,  761 
Fibroid,  recurrent,  116 

uterus,  1160 
Fibroma,  108 

bone,  487 

brain,  626 


Fibroma,  molluscum,  10S 

ueck,  732 

ovary,  1159 
Fibromyoma,  uterus,  1160 
Flbromyxoma,  109 
Fibrosarcoma,  117 
Fibrous  exostosis,  486 

osteitis,   163 
Fibula,  fracture,  415 
field  hospital,  190 
Figure-of-eight  bandage,  137 

suture,  164 
Filiform  bougies,  1070 
Filipuncture  in  aneurysm,  287 
Finger,  amputation,  224 

arthroplasty,  254 

contracture,  547 

supernumerary,  547 

trigger,  586 

webbed,  547 
Finney's  pyloroplasty,  930 
First  aid  station,  190 
Fissure,  anal,  960 

nipple,  749 

Rolando,  612 
Fistula,  47,  51 

in  ano,  959 

biliary,  983 

blind,  51 

branchial,  731 

Eck's,  996 

fecal,  946 

gastro-colic,  944 

genital,  1146 

internal,  944 

pancreatic,  1001 

pilo-nidal,  297 

pleural,  796 

Carrel-Dakin  treatment,  797 
decortication  of  lung,  797 
discission  of  pleura,  797 
thoracoplasty,  798 

recto-genital,  968 

recto-urethral,  968 

recto-urinary,  968 

recto-uterine,  968 

recto-vaginal,  968,  1146 

recto- vesical,  968 

salivary,  674 

thyro-glossal,  730 

treatment,  5i 

umbilical,  944 

urachal,  1017 

uretero-cervical,  1146 

urinary,  1082 

vesico-vaginal,  1146 
Fixed  dressings,  139 
Flap  amputation,  220 
Flat-foot,  591 
Floating  kidney,  1027 
Focal  epilepsy,  636 
Foot,  amputations,  230 

fractures,  419 
Forearm,  amputations,  226 

fractures,  392 
Foreign  bodies  in  air  passages,  715 


INDEX 


1181 


Foreign  bodies  in  appendix,  902 
in  bladder,  1026 
in  esophagus,  742 
in  inflammation,  18 
in  urethra,  1071 
Forster's  rhizotomy,  573 
Fourneaux-Jordan's  amputation,  234 
Fowler's  position,  S63 
Fractura  perforans,  361 
Fracture,  acetabulum,  361 

after-care,  342 

astragalus,  419 

Barton's,  392 

bursting,  603 

calcaneum,  419 

callus,  337 

carpus,  395 

causes,  330 

cerclage,  346 

chauffeur's,  392 

classification,  327 

clavicle,  363 

coccyx,  362 

Colles's,  388 

comminuted,  327 

complete,  327 

complicated,  328 
treatment,  346 

compound,  327 

treatment,  347 

by  cont recoup,  603 

costal  cartilage,  360 

by  counter-stroke,  603 

delayed  union,  339 

depressed,  328 

diagnosis,  334 

disability,  period  of,  343 

displacement,  332 

double,  327 

elbow,  375 

face  bones,  356 

femur,  398 

fibula,  415 

foot,  419 

forearm,  392 

green-stick,  327 

gunshot,  204 

hip,  39S 

humerus,  368 

impacted,  329 

incomplete,  327 

intra-uterine,  547 

ischium,  362 

larynx,  717 

longitudinal,  328 

malar,  356 

malunion,  treatment,  350 

mandible,  357 

maxilla,  356 

mechanism,  329 

metacarpus,  396 

metatarsus,  420 

multiple,  328 

by  muscular  action,  331 

nasal,  356 

non-union,  339,  352 


Fracture,  treatment,  353 

oblique,  328 

olecranon,  385 

patella,  408 

pathological,  331 

pelvis,  360 

phalanges,  fingers,  396 
toe,  420 

plating,  344 

Pott's,  416 

prognosis,  336 

radius,  387 

ribs,  359 

ring,  604 

sacrum,  362 

scapula,  367 

semilunar  cartilage,  448 

simple,  327 

operative  treatment,  343 

skeletal  traction,  340 

skiagraphy,  335 

skull,  602 

base,  609 
newborn,  608 
vault,  604 

spiral,  328 

splint,  341 

spontaneous,  331 

sprain,  331 

sternum,  358 

symptoms,  331 

tarsus,  419 

tibia,  412 

transportation,  204 

transverse,  328 

treatment,  339 

ulna,  385 

union,  process  of,  336 

ununited,  339,  352 
treatment,  353 

vertebra?,  640 

zygoma,  356 
Fragilitas  ossium,  454 
Frazier-Spiller  operation,  324 
Frontal  sinus,  706 

sinusitus,  705 
Frost-bite,  179 
Fungus  cerebri,  635 
Funnel  breast,  775 
Furuncle,  291 

of  ear,  676 
Fusiform  aneurysm,  280 

G 

Galactocele,  752 
Gall-bladder,  carcinoma,  997 

empyema,  975 

hydrops,  975 

operations,  984 

incisions,  871 

rupture,  894 

surgery,  974 
Gall-stones,  977 

in  common  duct,  981 

in  cystic  duct,  980 


IIS'J 


IX  !>!•:. X 


( lalt's  trephine,  608 
( langlion,  314 

gasserian,  extirpation,  324 
Gangrene,  57 

amputation,  60 

spontaneous,  59 

appendix,  901 

carbolic  acid,  59 

causes,  58 

diabetic,  58 

amputation,  GO 

dry,  59 

emphysematous,  59 

foudroyante,  88 

gas,  89 

sera,  91 

lino  of  demarcation,  59 
of  separation,  59 

lung,  799 

moist,  59 

pancreas,  1001 

senile,  58 

special  forms,  61 

symmetrical,  64 

symptoms,  59 

traumatic,  88 

treatment,  60 
Gangrenous  stomatitis,  63 
Gardener's  spade  deformity,  392 
Gas  gangrene,  89 

Gasserian  ganglion,  extirpation  of,  324 
Gastrectomy,  933 

Billroth's,  933 

Hartmann's  line,  926 

partial,  933 

subtotal,  935 

total,  936 
Gastric  ulcer,  916 
Gastro-anastomosis,  924 
Gastro-colic  fistula,  944 
Gastrogastrostomy,  924 
Gastro-intestinal  tract,  rupture  of,  893 

surgery,  900 
Gastrojejunal  ulcer,  933 
Gastrojejunostomy,  930 
Gastroplasty,  922 
Gastrostomy,  929 
Gastrotomy,  928 
Gelatinous  arthritis,  920 
Gely  suture,  881 
Genital  fistula,  1146 
Genitalia,  female,  examination,  1122 
Genitals,  female,  surgery,  1121 

male,  surgery,  1099 
Genu  varum,  57 
Gestation,  ectopic,  1147 
Giant-cell  myeloma,  112 

sarcoma,  112 
Gillies's  transplants,  243 
Glanders,  87 
Gleet,  1066 
Glioma,  115 

brain,  626 
Gliosarcoma,  117 
Glossitis,  695 

gummatous,  697 


( I  lot  1  is,  edema  of,  717 
(  Hue,  adhesive,  201 

Gluteal  abscess,  653 
Glycosuria,  alimentary,  1003 
Goiter,  733 

adenomatous,  736 
colloid,  734 
cystic,  734 
diffuse,  735 
exophthalmic,  737 
operation,  7  10 
treatment,  739 
nodular,  735 
operation,  736 
parenchymatous,  735 
treatment,  736 
Gonococcic  joint  infection,  514 

urethritis,  1065 
Gonorrhea,  1064 
female,  1127 

treatment,  prophylactic,  1066 
Graafian  follicle  cyst,  1 1  55 
Grant's  operation,  lip,  (590 
Granulation,  52 

tissue,  26,  30 
Granuloma,  infectious,  74 
Graves's  disease,  737 
Gridiron  incision,  872 
Gritti's  amputation,  233 
Guillotine  amputation,  217 
Gumma,  82,  1052 
of  breast,  753 
of  tongue,  696 
tuberculous,  76 
Gunshot  fractures,  205 
wounds,  190 

abdomen,  897 
bloodvessels,  203 
bones,  204 
diaphragm,  802 
duodenum,  898 
head,  208 
intestine,  211,  897 
joints,  206 
liver,  898 
lungs,  209 
nerves,  204 
pancreas,  899 
spine,  209 
spleen,  899 
stomach,  89S 
tendons,  204 
thorax,  209 
Guthrie's  amputation,  234 
Gypsum,  139 


H 

Hallux  valgus,  592 
Halsted's  suture,  882 
Hammer  toe,  592 
Hancock's  amputation,  231 
Hand,  amputation,  224 
Handley's  operation,  301 
Hare-lip,  682 


INDEX 


1183 


Hare-lip,  double,  684 

suture,  162 
Harrison's  groove,  456 
Hartmann's  line  for  gastrectomy,  826 
Head,  deformities,  579 

gunshot  wounds,  208 

operations,  anesthetic,  154 

surgery  of,  595 
Heart,  foreign  bodies  in,  269 

injuries,  268 

massage,  269 

rupture,  268 

wounds,  268 
Heat,  effects  of,  38 

prostration,  postoperative,  1S9 
Heberden's  nodes,  497 
Hectic  fever,  73 
Heel,  painful,  594 
Heliotherapy,  527 
Hemangeio-endothelioma,  130 
Hemangeioma,  276 
Hemarthrosis,  424 
Hematocele,  1118 
Hematocolpos,  1126 
Hematoma,  160 

auris,  676 

treatment,  265 
Hematometra,  1126 
Hematomyeha,  639 
Hematorrachis,  639 
Hemiatrophy,  facial,  710 
Hemilaryngectomy,  721 
Hemophilia,  259 
Hemoptysis,  783 
Hemorrhage,  259 

apparent,  259 

arterial,  259 

concealed,  259 

constitutional  signs,  259 

extradural,  619 

internal,  229 

intestinal,  in  typhoid,  945 

intracerebral,  621 

intradural,  620 

middle  meningeal,  619 

operative,  186 

primary,  186 

reactionary,  186 

secondary,  186,  264 

spinal  canal,  639 

spontaneous  arrest,  260 

subcranial,  619 

subcutaneous,  259 

treatment,  260 

venous,  259 
Hemorrhagic  pancreatitis,  999 

peritonitis,  856 
Hemorrhoids,  961 

clamp  and  cautery,  964 

ligation,  963 
Hemostasis,  Wyeth's  method,  227 
Hemothorax,  787 
Hepatic  duct,  gall-stone,  981 
Hepatico-enterostomy,  983 
Hepaticus  drainage,  988 
Hepatitis,  suppurative,  991 


Hcpatoptosis,  990 
Hepatotomy,  992 

Hereditary  deforming  chondrodysplasia, 
485 
syphilis,  1053 
Hermaphrodism,  1102 
Hernia,  805 
causes,  806 
cecal,  sliding,  836 
cerebri,  635 
classification,  822 
Cloquet's,  846 
congenital,  832 
Cooper's,  846 
crural,  845 
diaphragmatic,  802 
epigastric,  823 
femoral,  845 

operation,  847 

rare  forms,  846 

strangulated,  850 
of  Hesselbach,  846 
incarcerated,  813 
incisional,  824 
inflamed,  812 
inguinal,  831 

direct,  843 

rare  forms,  844 
treatment,  844 

oblique,  831 

operation,  839 
rare  forms,  836 
recurrence,  837 
strangulation,  835 

preperitoneal,  836 

trusses,  837 
inguino- crural,  836 
interna],  939 
interparietal,  836 
interstitial,  836 
irreducible,  811 
ischiatic,  852 
labial,  831 
Laugier's,  846 
Littre's,  807 
lumbar,  830 
lung,  786 
muscular,  304 
nomenclature,  805 
obstructed,  812 
obturator,  851 

operation,  contraindications,  810 
Partridge's,  846 
pectineal,  846 
perineal,  851 
pudendal,  851 
recurrence,  837 
reducible,  808 
retroperitoneal,  939 
retrovascularis,  846 
Richter's,  807 
sac,  806 

acquired,  807 

congenital,  807 

contents,  807 
sliding,  836 


MM 


INDEX 


Hernia,  special,  822 
strangulated,  813 

diagnosis,  816 
operation,  SIS 
treatment,  817 
structures,  son 

supravesical,  S  I  1 

taxis,  Ms 

of  Tessier,  Sit! 

treatment,  809 

truss,  810 

umbilical,  826 
adult,  827 
congenital,  826 
infantile,  826 
strangulated,  830 

vaginal,  851 

ventral,  823 
Ilerniotome,  819 
Herniotomy,  819 
Herpes  progenitalis,  1105 
Hesselbach's  hernia,  846 
Hey's  amputation,  230 
Hilton's  law,  522 

method  of  opening  abscesses,  50, 
Hip,  arthroplasty,  254 

central  dislocation,  361 

dislocation,  441 
congenital,  547 

excision,  539 

fracture,  398 

snapping,  588 

tuberculosis,  530 
Hip-joint  amputation,  233 
Hirschsprung's  disease,  955 
Hodgen's  splint,  205 
Hodgkin's  disease,  115,  302 
Hood  truss,  838 
Horn,  291 

Horse-shoe  kidney,  1026 
Horsley's  dural  separator,  607 

wax,  632 
Hospital,  base,  192 

evacuation,  190 

field,  190 

gangrene,  62 

trains,  192 
Hotchkiss's  meloplasty,  669 
Hour-glass  stomach,  923 
"Housemaid's  knee,"  298 
Hudson's  trephine,  633 
Humerus,  dislocation,  430 
reduction,  433 

fracture,  368 
Hunger-pain,  918 
Hunter's  ligation,  285 
Hutchinson's  teeth,  1055 
Hydatid  cyst,  liver,  993 

disease,  breast,  761 

of  Morgagni,  1157 
Hydrarthrosis,  507 
Hydrencephalocele,  597 
Hydrocele,  1115 

acquired,  1115 

acute,  1109 

canal  of  Nuck,  1117 


Hydrocele,  congenital,  111--* 

cord,  1117 
encysted,  1117 
operation,  1117 
tapping,  1117 

Hydrocephalus,  59S 

congenital,  600 

hypersecretory,  601 

obstructive,  599 
Hydronephrosis,  1031 
Hydrophobia,  96 
Hydrops  articuli,  503 

gall-bladder,  975 
Hydrorrachis,  637 
Hydrosalpinx,  1134 
Hydrothorax,  788 
Hygroma,  732 
Hyloma,  106 

Hymen,  imperforate,  1126 
Hyperemesis  lactantium,  921 
Hyperemia,  active,  20 

passive,  20 
Bier's,  40 
Hyperkeratosis,  123 
724    Hypernephroma,  129 

kidney,  1038 
Hyperostosis,  111 
Hyperthyroidism,  733,  737 
Hypertrophic  joint  lesions,  497 
Hypertrophy,  bone,  466 

prostate,  1084 
Hypodermic  injections,  145 
Hypodermoclysis,  146 
Hypoleukocytosis,  31 
Hypophysis,  tumors,  630 
Hypospadias,  1099 
Hypothyroidism,  733,  737 
Hysterectomy,  abdominal,  1165 

vaginal,  1166 
Hysteropexy,  1143 


Ichthyosis  of  tongue,  695 

Ileus,  936 

Iliac,  abscess,  864 

traumatic,  892 

Imperforate  anus,  956 
esophagus,  745 
hymen,  1126 
rectum,  957 
vulva,  1125 

Incarcerated  hernia,  813 

Incised  wounds,  160 

Incision,  abdominal,  870 
closure,  873 
suture,  881 
Davis's,  872 
Deaver's,  872 
gall-bladder,  984 
gridiron,  872 
kidney,  1040 
McBurney's,  872 
Mayo  Robson's,  872 
muscle-splitting,  872 


INDEX 


1185 


Incision,  simple,  872 
Sprengel's,  984 
transverse,  872,  984 
Incisional  hernia,  824 
Indian  rhinoplasty,  667 
Indigo-carmine  test,  1016 
Indolent  ulcer,  54 
Infantile  paralysis,  565 

stenosis,  pylorus,  921 
Infectious  granulomas,  74 
Infiltration  anesthesia,  158 
Inflammation,  17 
alexins,  23 
antitoxins,  23 
bacteriolysins,  23 
causes,  18 

bacteria,  18 

endotoxins,  19 

exciting,  18 

predisposing,  18 

toxins,  19 
chronic,  35 
cure,  37 
diapedesis,  20 
diseases  resulting  from,  46 
extension,  27 
fibroblasts,  22 
foreign  bodies,  18 
general  affections,  67 
leukocytes,  22 
leukocytosis,  31 
lymphs  23 
lymphization,  23 
lymphocytes,  22 
lymphogenesis,  23 
margination,  20 
migration,  20 
nervous  system,  27 
pathology,  19 

summary,  29 
phagocytosis,  23 
phlegmonous,  26 
polyblasts,  22 
pyrexia,  68 
regeneration,  30 
repair,  29 
resolution,  27 
resulting  affections,  70 
round-cell  infitration,  23 
symptoms,  31 

constitutional,  31 

heat,  33 

impaired  function,  34 

local,  32 

modification  of  nutrition,  35 

muscular  rigidity,  34 

pain,  33 

redness,  32 

swelling,  33 

tenderness  on  pressure,  34 
terminations,  27 
treatment,  35 

alteratives,  43 

Bier's  congestion,  40 

bleeding,  39 

cathartics,  42 
75 


Inflammation,  treatment,  cold,  38 
compression,  40 
congestion,  40 
constitutional,  41 
counter-irritants,  39 
diaphoretics,  42 
diet,  41 
diuretics,  42 
douches,  39 
heat,  38 
hygiene,  41 
incisions,  39 
irrigation,  38 
local,  37 
massage,  40 
narcotics,  39 
operations,  40 
position,  37 
prophylaxis,  35 
rest,  37 
sedatives,  41 
serum  therapy,  44 
stimulants,  42 

stimulation  of  phagocytosis,  43 
tonics,  43 
vaccins,  44 
venesection,  39 
Inflammatory  fever,  69 

lymph,  23 
Infusion,  axillary,  146 
intravenous,  146 
Ingrowing  toe-nail,  291 
Inguinal  hernia,  831 
direct,  843 

rare  forms,  844 
treatment,  844 
oblique,  831 

rare  forms,  836 
treatment,  837 
recurrence,  837 
strangulation,  835 
trusses,  837 
Inguino-crural  hernia,  836 
Injuries,  general  effects,  181 

local  effects,  159 
Insect  stings,  174 
Interparietal  hernia,  836 
Interphalangeal  dislocation,  441 
Interrupted  suture,  162 
Interscapulo-thoracic  amputation,  230 
Interstitial  hernia,  836 
Intestinal  anastomosis,  884 
end-to-end,  885 
lateral,  886 
exclusion,  949 
hemorrhage  in  typhoid,  945 
injuries,  892,  897 
localization,  877 
obstruction,  936 
acute,  937 
chronic,  942 
perforation  in  typhoid  fever,  944 
resection,  882 
sutures,  880 

tract,  internal  fistulsc,  944 
Intestine,  surgery,  936 


use, 


/.\i)i:\ 


Intestine,  tumors,  9 18 
Intoxication,  68 
Intracerebral  hemorrhage,  G21 

Intracranial  hemorrhage  in  m  wborn,  621 
[ntradural  hemorrhage,  020 
Intrathoracic  op  rations,  anesthetic,  155 
Intratracheal  Insufflation,  155 
Intravenous  transfusion,  146 
intubation,  718 
Intussuseept  ion,  93N 

appendix,  916 
Involucrum,  469 
Iodin  disinfection,  143 
Irreducible  hernia,  si  1 
Irrigation,  bladder,  1019 

Petitgand's,  38 
Irritable  ulcer,  53 
Ischemic  contracture,  583 
[schiatic  hernia,  852 
Ischiorectal  abscess,  958 
Ischium,  fractures,  362 
Italian  rhinoplasty,  668 


Jabotjlay's  operation,  1117 
Jacksonian  epilepsy,  636 
Jackson's  membrane,  951 
Jacob's  ulcer,  124 
Jaw,  carcinoma,  710 

fractures,  356,  357 

necrosis,  708 

osteomyelitis,  707 

sarcoma,  711 

subluxation,  428 

surgery,  707 

tumors,  710 
Jejunostomy,  929 
Jejunum,  peptic  ulcer,  933 
Joint,  ankylosis,  508 

arthrectomy,  529 

atrophy,  493 

Charcot's,  497 

contusion,  421 

diseases,  429 

dystrophy,  492 

erasion,  529 

gunshot  wounds,  206 

hypertrophic,  497 

infection,  503 

gonococcic,  514 
metastatic,  acute,  515 

chronic,  516 
pneumococcic,  514 

injuries,  421 

loose  bodies  in,  502 

mice,  502 

neuropathic,  502 

sarcoma,  545 

sprain,  421 

syphilis,  545 

tuberculosis,  519 

tumors,  545 

wounds,  422 

treatment,  423 
Jugular  vein,  resection,  622 


Keen's  point,  cranium,  600 

Kelly's  cystoscopc,  1015 
Keloid,  109 
Kelotomy,  819 
Keratosis  senilis,  669 
Kidney,  anomalies,  1026 

calculus,  1032 

carcinoma,  1038 

cysts,  1038 

decapsulation,  1028 

dislocated,  1027 

floating,  1027 

function,  tests,  1016 

gunshot  wound,  1039 

horseshoe,  1026 

hydronephrosis,  1031 

hypernephroma,  1038 

infections,  1028 

injuries,  1039 

movable,  1027 

needling,  1035 

operations,  1039 

rupture,  1039 

sarcoma,  1038 

stab  wound,  1039 

stone,  1032 

surgery,  1013,  1026 

surgical,  1030 

tuberculosis,  1036 

tumors,  1038 

differential  diagnosis,  1007 
Killian's  operation,  707 
Kink  of  ileum,  Lane's,  951 
Knee  amputation,  232 

arthroplasty,  255 

dislocation,  445 

congenital,  558 

excision,  510 

synovitis,  505 

tuberculosis,  541 
Knee-joint,  internal  derangement,  445 
Knock-knee,  457 
Knots,  166 
Kocher's  incision  for  goiter,  736 

point,  cranium,  600 
Kollman's  urethral  dilator,  1078 
Kondoleon's  operation,  301 
Kraske's  operation,  971 


Labarraqtje's  solution,  170 
Labial  cysts,  688 
Lacerated  wounds,  166 
Laceration  of  cervix,  1138 

of  perineum,  1139 
Lacteal  calculi,  753 
Lacunar  resorption,  454 
Laminectomy,  647 
Lane's  kink,  951 

operation,  cleft  palate,  687 
Laparotomy,  869 
Larrey's  amputation,  234 


INDEX 


1187 


Laryngectomy,  721 
Laryngo-fissure,  721 
Laryngoscopy,  717 
Larynx,  carcinoma,  717 
extirpation,  721 
fracture,  717 
intubation,  718 
tumors,  717 
Lateral  anastomosis,  886 
sinus,  612 

ventricles,  tapping,  600 
Laugier's  hernia,  846 
Leeching,  148 
Lee's  amputation,  232 
Leg,  amputation,  232 

ulcer,  55 
Legg's  disease,  588 
Leiomyoma,  115 
Leiter's  coil,  38 
Lembert  suture,  880 
Leontiasis  ossea,  466 
Lepidoma,  106 

transitional,  128 
Leptomeningitis,  623 
Leukocytosis,  31 
Leuko-keratosis,  695 
Leukoplakia,  695 
Ligation  of  arteries,  262 
of  hemorrhoids,  963 
Lightning  strokes,  180 
Ligneous  phlegmon,  neck,  722 
Line  of  demarcation,  59 

of  separation,  59 
Linitis,  plastic,  925 
Lip,  carbuncle,  688 
epithelioma,  688 
surgery,  682 
Lipoma,  107 

arborescens,  545 
breast,  762 
neck,  732 
Liquor  puris,  26 
Lisfranc's  amputation,  230 
Lithectasv,  1025 
Litholapaxy,  1023 
Lithotomy,  1025 

perineal,  1026 
Lithotrity,  1023 
Litigation  spine,  639 
Littre's  hernia,  807 

operation,  colotomy,  943 
Liver,  abscess,  991 
carcinoma,  996 
cirrhosis,  995 
corset,  990 

cyst,  echinococcus,  993 
gumma,  1053 
gunshot  wounds,  898 
rupture,  893 
sarcoma,  997 
surgery,  990 
tumors,  996 
Lockjaw,  91 
Lock-stitch  suture,  163 
Longitudinal  sinus,  rupture,  608 
thrombosis,  621 


Ludwig's  angina,  693 
Lumbar  abscess,  653,  864 

hernia,  830 
Lumpy  jaw,  83 
Lung,  abscess,  799 

decortication,  797 

gangrene,  799 

hernia,  786 

subcutaneous  injuries,  782 

surgery,  782 

tuberculosis,  799 

tumors,  801 
Lupus,  670 

vulgaris,  294 
Luxatio  erecta,  431 
Luxation,  424 
Lymph,  inflammatory,  23 
Lymphadenitis,  299 

mediastinum,  781 

neck,  723 
Lymphangeio-endothelioma,  130 
Lymphangeioma,  300 
Lymphangeioplasty,  301 
Lymphangeitis,  299 
Lymphangiectasis,  300 
Lymphatic  varicocele,  300 
Lymphatics,  diseases  of,  299 

injuries,  299 

wounds,  299 
Lymphedema,  300 
Lymphization,  23 
Lymphogenesis,  23 
Lymphomatosis,  114,  302 
Lymphorrhea,  299 
Lymphosarcoma,  117,  304 
Lyssa,  96 

M 

McBurney's  incision,  872 

point,  903 
Macrocheilia,  688 
Microglossia,  692 
Macromelia,  300 
Madelung's  deformity,  585 
Madura  foot,  84 
Malar  bone,  fracture,  356 
Malignant  lymphoma,  302 

myoma,  117 

osteoma,  488 

pustule,  85 
Mallein  test,  87 
Mammary  abscess,  750 

cancer,  764 

gland,  753.     See  Breast. 
Mandible,  dislocation,  428 

excision,  712 

fracture,  357 
Mania  a  potu,  184 
Manus  valga,  585 
Margination,  20 
Mar  John's  ulcer,  157 
Mastitis,  acute,  749 

carcinomatous,  768 

chronic,  751 
cystic,  756 


L188 


l.XDKX 


Mastodynia,  751 
Mastoiditis,  acute,  678 
d]  eral  ion,  679 

M:it:is's  operation,  ruicurysin,  288 
Mattress  suture,  L63,  882 
Maunsell's  operation,  885 
Maxilla,  fracture,  :'>•"><> 

inferior,  excision,  712 

superior,  excision,  712 
Maxillary  antrum,  700 

sinusitis,  70") 

tumors,  000 
Ma\o  |{<)l)S(in's  incision,  S72 
Meckel's  diverticulum,  943 

Mediastinitis,  acute,  7S1 
Mediastinum,  surgery,  781 
Mediotarsal,  amputation,  231 

dislocation,  453 
Megacolon,  955 
Melanoma,  130 
Melon-seed  bodies,  520 

Meloplasty,  072 
Membrane,  Jackson's,  951 
Menciere's  solution,  172 

technique,  172 
Meningitis,  023 

serous,  chronic  spinal,  005 

tuberculous,  023 
Meningocele,  597,  037 
Meningomyelocele,  037 
Mercier  catheter,  1090 
Merocele,  845 
Mesenteric  cysts,  949 

embolism,  943 

thrombosis,  943 
Mesosigmoiditis,  952 
Mesothelioma,  128,  129 
Metacarpus,  dislocation,  440 

fracture,  390 
Metastatic  abscess,  71 

arthritis,  515 
Metatarsalgia,  anterior,  590 
Metatarsus,  dislocation,  453 

fracture,  420 
Metritis,  1131 

septic,  1151 
Michel's  clamps,  100 
Microcephalia,  598 
Microdactylia,  300 
Micrognathy,  709 
Middle  meningeal  artery,  019 
Migration,  20 
Mikulicz's  disease,  074 
"Miner's  elbow,"  298 
Minor  surgery,  144 
Missiles,  192 
Mobile  units,  191 
Mole,  pigmented,  270 
Molecular  death,  58 
Molluscum  fibrosum,  320 
Momburg's  method  of  hemostasis,  235 
Monorchidism,  1107 
Morbus  coxse  senilis,  498 
Morgagni,  hydatid  of,  1157 
Mortification,  57 
Morton's  toe,  590 


Mosetig-Moorhof  wax,  478 

"  Mother's  mark,"  270 

Movable  kidney,  L027 

spleen,  1009 
Mucous  patches,  1050 

tongue,  696 
Multiple  neurofibromatosis,  326 
Mummery's  operation,  905 
Murphy  button,  890 
Muscle,  congenital  absence,  540 

contracture,  307 

disease  of,  304 

hernia,  304 

rupture,  305 

transplants,  245 

tumors,  309 

wounds,  304 
Muscle-splitting  incision,  S72 
Muscular  rigidity,  34 
Mustard-gas  burns,  178 
Myelocele,  037 
Myelogenous  leukemia,  114 
Myeloid  tumors  of  tendon  sheath,  129 
Myeloma,  112 

giant-celled,  112 
Myelomatosis,  114 
Myoma,  115 

malignant,  117 

sarcomatodes,  117 

of  uterus,  1 100 
Myomectomy,  1104 
Myo-sarcoma,  117 
Myositis,  305 

ossificans,  306 
Myringotomy,  078 
Myxedema,  737 
Myxo-lipoma,  107 
Myxoma,  109 
Myxo-sarcoma,  109 


N 

Nasal  bones,  fracture,  350 
Nasopharynx,  tumors,  715 
Neck,  abscess,  724 

cut -throat,  722 

deformity,  579 

fioroma,  732 

ligneous  phlegmon,  722 

lipoma,  732 

lymphadenitis,  723 
tuberculous,  724 

operations,  anesthetic,  154 

surgery,  722 

wounds,  722 
Necrosis,  57 

appendix,  901 

bone,  474 

jaws,  708 
Needles,  104 
Needling  kidney,  1035 
Negri  bodies,  97 
Nekton's  dislocation,  452 

line,  400 

operation,  083 


INDEX 


1189 


Neoplasm.     See  Tumors. 
Nephrectomy,  1043 
Nephritis,  septic,  1029 

toxic,  1028 
Nephrolithiasis,  1032 
Nephrolithotomy,  1035,  1041 
Nephropexy,  1028 
Nephroptosis,  1027 
Nephrotomy,  1035,  1041 
Nerve,  blocking,  158 

dislocation,  316 

gunshot  wounds,  204 

injuries,  315 

suture,  318 

tumors,  326 

wounds,  317 
Neuralgia,  322 

breast,  751 

epileptiform,  322 

minor,  322 

sciatic,  325 

testicle,  1110 

trifacial,  322 
Neuralgic  ulcer,  53 
Neurectasis,  sciatic  neuralgia,  325 
Neurinoma,  326 
Neuritis,  320 
Neurofibromatosis,  326 
Neurolysis,  317 
Neuroma,  115 

amputation,  326 

plexiform,  326 
Neuropathic  joints,  502 
Neuroplasty,  319 
Neurorrhaphy,  318 
Neurotic  spine,  578 
Neurotomy,  322 
Nevoid  lipoma,  277 
Nevus,  276 

Newborn,  intracranial  hemorrhage,  621 
Nicoll's  operation,  cranium,  608 
Nipple,  affections,  748 

excoriation,  749 

fissure,  749 

Paget's  disease,  768 

retraction,  765 
Nitrous  oxide,  153 
Noma,  62 

pudendi,  63 
Non-union,  fractures,  352 
Nose,  foreign  body,  667 

saddle,  1055 

surgery  of,  666 
Nosebleed,  666 
Novocain  anesthesia,  157 


Obstruction,  common  duct,  983 
intestinal,  936 
acute,  937 
chronic,  942 
operation,  941 
pyloric,  920 
Obturator  hernia,  851 


Ochsner  treatment,  862 
Odontoma,  112 
Olecranon  fracture,  385 
Omental  cysts,  949 
Omphalectomy,  829 
Onychauxis,  291 
Onychia,  291 
Oophorectomy,  1137 

carcinoma,  breast,  774 
Oophoritis,  1135 
Operation,  abdominal,  869 

after-treatment,  876 
injuries,  894 

preparation  of  patient,  875 
section,  869 
technique,  874 

ablation  of  breast,  770 

Agnew's,  webbed  fingers,  549 

air  passages,  718 
sinuses,  705 

Albee's,  spinal,  659 

Alexander's,  round  ligaments,  1143 

amputation,  212 
breast,  759 
penis,  1106 

Anel's  ligation,  285 

anesthesia,  149 

aneurysm,  285 

aneurysmoplasty,  288 

Antyllus,  aneurysm,  287 

appendicectomy,  906 

appendicostomy,  950 

arteriorrhaphy,  266 

arthrectomy,  529 

arthrodesis,  570 

arthrolysis,  509 

arthroplasty,  252 

Ashhurst's  amputation,  232 

astragalectomy,  565 

Bassini's,  hernia,  839 

Beck's,  hypospadias,  1100 

Berger's  amputation,  230 

bile-duct,  984 

Billroth's  amputation,  235 
gastrectomy,  933 

Bottini's,  prostatic,  1091 

Brasdor's,  for  aneurysm,  286 

Cantwell's,  hypospadias,  1102 

carcinoma  of  breast,  770 
of  tongue,  700 

cardiolysis,  269 

castration,  1113 

cecostomy,  950 

cholecystectomy,  986 

cholecystenterostomy,  989 

cholecysto-duodenostomy,  989 

cholecystostomy,  985 

cholecystotomy,  985 

choledocho-enterostomy,  989 

choledochostomy,  987 

choledochotomy,  9S7 

chondrectomy,  799 

Chopart's  amputation,  231 

circumcision,  1103 

cleft  palate,  685 
'  Cock's,  urethrotomy,  1080 


into 


INDEX 


Operation,  colostomy,  969 
colporrhaphy,  1 1  I" 
costo-transversectomy,  660 
cricothyrotomy,  719 
Cushing's  decompressive,  634 
cystocele,  1146 
cystotomy,  1025 
debridement,  201 
decompressive,  craniectomy,  634 
decortication  of  lung,  797 
Demarquay's  urethrotomy,  1073 
Didot's,  webbed  fingers,  ">  lit 
Dieffenbach's  amputation,  234 
discission  of  pleura,  797 
Dudley's,  anteflexion,  1127 
Dupuytren's  amputation,  228 
duodeno-cholcdochostomy,  989 
Edebohls's,  kidney,  1028 
endo-aneurysmorrhaphy,  288 
enterotomy,  941 
epiplopexy,  996 
epluchage,  200 
erasion  of  joints,  529 
esopliagotomy,  743 
esquillectomy,  205 
Est  lander's,  thorax,  798 
evidement,  478 
excision,  elbow,  510 
hip,  539 
knee,  510 
maxilla,  inferior,  712 

superior,  712 
rib,  792 
shoulder,  513 
tongue,  704 
tumors,  132 
wrist,  513 
extirpation  of  aneurysm,  288 
of  Gasserian  ganglion,  324 
of  penis,  1 106 
Ferguson's,  hernia,  843 
Fergusson's,  cleft  palate,  685 
Finney's  pyloroplasty,  930 
Forster's  rhizotomy,  573 
fractures,  344 

ununited,  354 
Frazier-Spiller,  324 
gall-bladder,  984 
gastrectomy,  933 
gastro-anastomosis,  924 
gastrogastrostomy,  924 
gastrojejunostomy,  930 
gastroplasty,  924 
gastrostomy,  929 
gastrotomy,  928 
goiter,  736 

exophthalmic,  740 
Grant's,  cancer  of  lip,  690 
Gritti's  amputation,  233 
Guthrie's  amputation,  234 
Hancock's  amputation,  231 
Handley's,  301 
hemi  laryngectomy,  721 
hepaticus-drainage,  988 
hepatotomy,  992 
hernia,  839,  847 


Operation,  hernia,  strangulated,  818 
herniotomy,  819 
Hoy's  amputation,  231 
Hotchkiss's  meloplasty,  669 
Hunter's,  aneurysm,  285 
hydrocele,  1117 
hysterectomy,  abdominal,  1165 

vaginal  1166 
hysteropexy,  1143 
intestinal  anastomosis,  884 

exclusion,  949 
Jaboulay's,  hydrocele,  1117 
jejunostomy,  929 
kelotomy,  819 
kidney,  1039 
Killian's,  707 
Kraske's,  971' 
laminectomy,  647 
Lane's,  cleft  palate,  687 
laparotomy,  869 
Larrey's  amputation,  234 
laryngectomy,  721 
Lee's  amputation,  232 
ligation  for  aneurysm,  285 
of  arteries,  261 
of  hemorrhoids,  963 
Lisfranc's  amputation,  230 
lithectasy,  1025 
litholapaxy,  1023 
lithotomy,  1025 
lithotrity,  1023 
Littre's,  colotomy,  943 
lymphangeioplasty,  301 
mastoiditis,  acute,  679 
Matas's,  aneurysm,  288 
Maunsell's,  intestinal  resection,  885 
Mayo's,  umbilical  hernia,  828 
meloplasty,  672 

Mummery's,  prolapse  of  rectum,  965 
myomectomy,  1164 
myringotomy,  678 
Nelaton's,  hare4ip,  683 
nephrectomy,  1043 
nephrolithotomy,  1035 
nephropexy,  1028 
nephrotomy,  1035,  1041 
nettoyage,  200 
neurectomy,  288 
neurolysis,  317 
neuroplasty,  319 
Nicoll's,  cranium,  608 
omphalectomy,  829 
oophorectomy,  1137 
orchidectomy,  1113 
orchidopexy,  1108 
osteotomy,  458 
ovariotomy,  1159 
pericardiotomy,  269 
perineorrhaphy,  1140 
pharyngotomy,  714 
phlebectomy,  275 
phlebotomy,  148 
Pirogoff  s  amputation,  231 
plastic,  240 
pleurotomy,  792 
plombage,  478 


INDEX 


1191 


Operation,  pneumonectomy,  799 
pneumonotomy,  799 
Pozzi's,  cervix  uteri,  1127 
proctotomy,  967 
prostatectomy,  perineal,  1096 

suprapubic,  1093 
prostatotomy,  perineal,  1091 
pyelotomy,  1035 
pylorectomy,  933 
pyloroplasty,  930 
Rammstedt's  pyloroplasty,  921 
resection,  intestinal,  882 

jugular  vein,  622 

skull,  632 
rhinoplasty,  667 
rhizotomy,  573 
Ruggi's,  femoral  hernia,  849 
salpingectomy,  1137 
salpingo-oophorectomy,  1136 
Scbede's,  thoracoplasty,  798 

varicose  veins,  275 
S'chroeder's,  cervix  uteri,  1130 
Sedillot's  amputation,  704 
sequestrotomy,  475 
short-circuiting,  949 
sigmoido-proctostomy,  967 
Skey's  amputation,  230 
skin-grafting,  236 
Spence's  amputation,  227 
splenectomy,  1011 
Stamm's  gastrostomy,  929 
staphylorrhaphy,  685 
Stokes's  amputation,  233 
stomach,  928 
Syme's  amputation,  231 

urethrotomy,  1078 
sympathectomy,  741 
tarsectomy,  cuneiform,  564 
Teale's  amputation,  232 
tendon  transplantation,  568 
tenotomy,  563 

Terrier's,  choledochotomy,  986 
Textor's  amputation,  231 
thoraco-laparotomy,  802 
thoracoplasty,  798 
thoracotomy,  792 
thyroidectomy,  740 
thyrotomy,  731 
tracheoplasty,  1138 
trachelorrhaphy,  1138 
tracheotomy,  719 

Trendelenburg's,  varicose  veins,  275 
trephining  skull,  608 
ureterolithotomy,  1036 
ureteroplasty,  1037 
urethrotomy,  1077 
vaginal  hysterectomy,  1 166 
ventro-fixation  of  uterus,  1144 
Wardrop's  ligation,  286 
Whitehead's,  excision  of  tongue,  704 

hemorrhoids,  963 
wiring  aneurysm,  287 
Witzel's  gastrostomy,  929 
Opsonins,  23 
Orchidectomy,  1113 
Orchidopexy,  1108 


Orchitis,  1108 
Orthopedic  surgery,  546 
Osteitis,  468 

deformans,  463 

fibrocystic,  463 
Osteo-arthritis,  493 
Osteo-arthropathy,  pulmonary,  518 
Osteochondritis      deformans     juvenilis, 

588 
Osteoclasis,  458 
Osteogenesis  imperfecta,  454 
Osteoid  sarcoma,  488 
Osteoma,  111 

malignant,  488 

sarcomatodes,  488 
Osteomalacia,  461 
Osteomyelitis,  468 

albuminous,  471 

chronic,  473 

infancy,  479 

jaw,  707 

ribs,  781 

skull,  611 

vertebrae,  648 
Osteophyte,  111 
Osteoporosis,  454 
Osteopsathyrosis,  454 
Osteosarcoma,  117,  487 
Osteotomy,  458 

subtrochanteric,  529 
Ostoses,  111 
Othematoma,  676 
Otitis  media,  677 
Ovariotomy,  1159 
Ovaritis,  1135 
Ovary,  abscess,  1135 

carcinoma,  1159 

cyst,  1155 

dermoid,  115S 
retention,  1154 

cystadenoma,  1155 

embryomas,  1158 

fibroma,  1159 

teratomas,  1158 

tumors,  1155 
Oxycephaly,  601 


Pachymeningitis,  623 
Paget's  disease  of  bone,  463 

of  nipple,  768 
Pain  in  inflammation,  33 

referred,  33 
Painful  heel,  594 
Palate,  cleft,  682 

perforation,  687 

surgery,  682 
Pahnar  abscess,  313 

fascia,  contracture  of,  585 
Palsy,  brachial  birth,  556 

cerebral,  572 

crutch,  316 

infantile,  5(15 


1192 


/\i)i:x 


Palsy,  post-anesthetic,  310 
Panaris,  :'>1 1 
Pancreas,  abscess,  1001 

carcinoma,  L004 

cysts,  L006 

gangrene,  1001 

gunshot  wounds,  899 

infections,  !)'.)S 

surgery,  90S 
Pancreatectomy,  L005 
Pancreatic  calculi,  1004 

fistula,  1007 

insufficiency,  1002 

lymphangeitis,  1001 
Pancreatitis,  acute,  999 

chronic,  1001 

hemorrhagic,  999 
Pancreatoenterostomy,  1006 
Pan-hysterectomy,  1166 
Papilloma,  119 

of  bladder,  1021 

intracystic,  120 

of  larynx,  717 
Paralytic  calcaneus,  568 

deformities,  565 

equino-varus,  566 

talipes,  565 

valgus,  565 
Paraphimosis,  1104 
Parasitic  cysts,  132 
Parathyroids,  739 
Park's  solution,  145 
Paronychia,  311 
Parosteal  abscess,  469 
Parotid  bubo,  672 

tumor,  672 
Parotitis,  infectious,  672 
Parovarian  cyst,  1156 
Partridge's  hernia,  846 
Pasteur  treatment  for  rabies,  99 
Patella,  dislocation,  448 

fracture,  408 
Pathology  of  inflammation,  19 
Paul's  tube,  942 
Peck's  operation,  rectum,  971 
Pectineal  hernia,  846 
Pelvic  abscess,  864,  1153 
Pelvis,  fracture,  360 

static  disorders,  578 
Pendulous  abdomen,  953 
Penis,  amputation,  1106 
carcinoma,  1105 
congenital  deformities,  1099 
extirpation,  1106 
surgery,  1099 
Peptic  ulcer  of  jejunum,  933 
Perforating  ulcer,  291 
Perforations  in  typhoid,  944 

of  uterus,  1151 
Perianal  abscess,  958 
Periarthritis,  507 
Pericardiotomy,  269 
Pericholecystitis,  975 
Pericolitis,  950 

sinistra,  952 
Periductal  fibroma,  760 


Periductal  myxoma,  760 
Perimetritis,  1151 

Perineal  hernia,  851 

lithotomy,  1026 

prostatectomy,  1096 

section,  1079 
Perineoplasty,  1140 
Perinephric  abscess,  1031 
Perineum,  laceration,  1139 
Perinorrhaphy,  1140 
Periosteitis,  acute,  467 

alveolus,  710 

chronic,   His 

rib,  787 
Perisigmoiditis,  952 
Perithelioma,  130 
Peritoneal  adhesions,  865 
Peritoneum,  853 

tuberculosis,  866 
Peritonitis,  S.",.'J 

acute,  856 

diffuse,  857 

operation,  914 

fibrino-purulent,  855 

general,  856 

hemorrhagic,  856 

Ochsner  treatment,  862 

operation,  indications,  861 
technique,  914 

pathology,  854 

pelvic,  1132 

pneumococcic,  866 

septic,  856 

spreading,  855 

symptoms,  856 

toxic,  856 

treatment,  861 
Ochsner,  862 
starvation,  862 
Peritonsillar  abscess,  713 
Peri-urethral  abscess,  1082 
Pernio,  180 
Perthes's  disease,  588 
Pes  planus,  591 
Petechia,  159 
Phagedenic  ulcer,  53 
Phagocytes,  23  * 

Phagocystosis,  23 
Phalanx,  finger,  dislocation,  441 
fracture,  396 

toe,  dislocation,  453 
fracture,  420 
Pharyngotomy,  714 
Phenol-sulphonephthalein  test,  1016 
Phimosis,  1102 
Phlebectasis,  274 
Phlebectomy,  275 
Phlebitis,  270 

post-operative,  272 

treatment,  272 
Phleboliths,  270 
Phlebosclerosis,  270 
Phlebotomy,  148 
Phlegmasia  alba  dolens,  272 
Phlegmon,  26,  46 
neck,  722 


INDEX 


1193 


Picric  acid  disinfection,  143 
dressing;,  178 

Pigmented  mole,  276 

Piles,  961 

Pilo-nidal  cyst,  297 

Pirogoff' s  amputation,  231 

v.  Pirquet's  test,  79 

Plaster  jacket,  656 

Plaster  of  Paris,  139 

Plastic  linitis,  925 

surgery,  236,  240 

bone  transplant,  248 
cartilage  transplant,  247 
fascia  transplantation,  246 
fat  transplantation,  246 
free  transplants,  285 
Gillies's  transplants,  243 
tendon  transplantation,  246 
transfer  of  muscles,  245 

Plating  fracture,  384 

Pleura,  discission,  797 
surgery,  782 
tuberculosis,  798 
tumors,  801 

Pleural  fistula,  796 

Carrel-Dakin  treatment,  797 
Estlander's  operation,  798 
Schede's  operation,  798 
thoracoplasty,  798 
vomica,  789 

Pleurisy,  788 

Pleuritis,  788 

Pleurotomy,  792 

Plexiform  neuroma,  326 

Plombage,  478 

Pneumococcic  joint  infection,  514 
peritonitis,  866 

Pneumohemothorax,  788 

Pneumonia,  post  operative,  185 

Pneumonectomy,  799 

Pneumonotomy,  799 

Pneumothorax,  782,  786 
tension,  787 

Poisoned  wounds,  174 

Poliomyelitis,  acute,  anterior,  565 

Polydactylism,  547 

Polymastia,  748 

Poly]),  nasopharyngeal,  715 
rectal,  968 
uterine,  1162 

Polythelia,  748 

"Port-wine"  stain,  276 

Post-anesthetic  palsy,  316 

Post-operative  deaths,  185 
embolism,  272 
phlebitis,  272 

Posthitis,  1105 

Pott's  disease,  649 

abscess,  652 

treatment,  659 
fixation  of  spine,  659 
paraplegia,  655 
treatment,  655 
fracture,  416 

Poultices,  38 

Pourriture  d'Hopital,  62 


Pozzi's  operation,  cervix  uteri,  1127 
Pregnancy,  extra-uterine,  1147 
Prepuce,  adherent,  1102 
Preputial  calculus,  1105 
Procain  anesthesia,  157 
Procidentia  recti,  961 

uteri,  1145 
Proctitis,  965 
Proctoclysis,  146 
Proctoscope,  955 
Proctotomy,  967 
Profeta's  law,  1054 
Prolapse,  rectum,  964 

urethra,  1074 

uterus,  1145 
Prostate,  abscess,  1083 

adenomatosis,  1085 

atrophy,  1097 

carcinoma,  1097 

enlargement,  1084 
treatment,  1089 

hypertrophy,  1084 

sarcoma,  1098 

surgery,  1083 
Prostatectomy,  perineal,  1096 

suprapubic,  1093 
Prostatitis,  1083 
Prostatotomy,  perineal,  1091 
"Proud  flesh,"  52 
Psammoma,  130 
Pseudoarthrosis,  352 
Pseudoleukemia  infantium,  1011 
Pseudomyxoma  peritonei,  1156 
Psoas  abscess,  653 
Psychical  shock,  184 
Ptomains,  19 
Pudendal  hernia,  851 
Puerperal  pyemia,  1150 

sepsis,  1150 
"Pulled  elbow,"  439 
Pulmonary  embolism,  187 

emphysema,  799 

osteo-arthropathy,  518 
Punctured  wounds,  173 
Pus,  24 
Pus-tube,  1133 

rupture,  1134 
Pyarthrosis,  503 
Pyelitis,  1029 
Pyelonephritis,  1029 
Pyelotomy,  1035,  1042 
Pyemia,  70 

puerperal,  1154 
Pylephlebitis,  991 
Pylorectomy,  933 
Pyloric  obstruction,  920 
Pyloroplasty,  930 
Pylorospasm,  921 
Pylorus,  exclusion,  931 

infantile  stenosis,  921 
Pyogenesis,  24 
Pyogenic  bacteria,  28 

membrane,  26 
Pyonephrosis,  1031 
Pyosalpinx,  1133 
Pyothorax,  789 


1194 


INDEX 


Quilled  suture,  163 
Quill  suture,  1G3 
Quinsy,  713 


Rabies,  96 

treatment,  99 
Racemose  aneurysm,  278 
Rachischisis,  637 
Rachitic  rosary,  450,  775 
Rachitis,  455 

Radio-carpal  dislocation,  440 
Radium,  therapeutic  uses,  181 
Radius,  dislocation,  438 

fracture,  387 
Railway  spine,  639 
Rammstedt's  pyloroplasty,  921 
Rankenneuroma,  326 
Ranula,  692 
Ray  fungus,  82 
Raynaud's  disease,  64 
v.  Recklinghausen's  disease  of  bone, 

of  skin,  326 
Reconstructive  surgery,  236 
Rectocele   1139 

Recto-genital  fistula,  968,  1146 
Recto-urinary  fistula,  968,  1146 
Rectum,  adenoma,  968 

carcinoma,  968 

false  anus,  969 
radical  operation,  970 

congenital  malformations,  956 

examination,  955 

imperforate,  957 

prolapse,  964 

stricture,  966 

surgery,  955 

tumors,  968 
Redressement  force,  563 
Regeneration,  30 
Relaxation  suture,  164 
Renal  calculus,  1032 

colic,  1034 
Repair,  wound,  161 
Resection,  intestinal,  882 
Residual  abscess,  856,  864 

urine,  1070 
Retained  secundines,  1150 
Retention  of  urine,  1070 
-  Retraction  of  nipple,  765 
Retroduodenal  choledochotomy,  988 
Retroflexion,  uterus,  1143 
Retrognathism,  709 
Retroperitoneal  hernia,  939 
Retropharyngeal  abscess,  652 
Retroversion,  uterus,  1143 
Reverdin's  skin-grafting,  237 
Rhabdomyoma,  115 
Rhagades,  1055 
Rheumatism,  tuberculous,  517 
Rhinophyma,  667 
Rhinoplasty,  667 
Rhinoscleroma,  85 


463 


Rhizotomy,  573 
Ribs,  caries,  780 

cervical,  582 

excision,  792 

fracture,  359 

osteomyelitis,  781 

periostitis,  781 
Rice  bodies,  520 
Richter's  hernia,  S07 
Riedel's  lobe,  990 
Rigidity  of  abdominal  wall,  857 
Ring  fracture,  604 
Rodent  ulcer,  124,  670 
Roller  bandage,  137 
Rose  ulcer,  766 

Ruggi's  operation,  femoral  hernia,  S49 
Rupture,  abdominal  wall,  <S91 

bladder,  1026 

diaphragm,  802 

gall-bladder,  894 

gastro-intestinal  tract,  893 

heart,  268 

kidney,  1039 

liver,  893 

longitudinal  sinus,  608 

lung,  782 

muscle,  305 

nerve,  316 

pus-tube,  1134 

spleen,  894 

tendon,  309 

urethra,  1072 


"Sabre-blade  deformity,"  484,  1055 
Sac  of  hernia,  806 
Saccular  aneurysm,  280 
Sacro-iliac  dislocation,  441 

tuberculosis,  544 
Sacrum  fractures,  362 
Saddle  nose,  667 
Saint  Anthony's  fire,  65 
Saline  solution,  145 
Salivary  calculus,  675 

fistula,  674 

glands,  chronic  inflammation,  675 

surgery,  672 

tuberculosis,  672 
Salpingectomy,  1137 
Salpingitis,  1132 
Salpingo-oophorectomy,  1 136 
Salvarsan,  1057,  1060 
Sapremia,  72,  1150 
Sarcocele,  1113 
Sarcoma,  115 

alveolar,  116 

bone,  487 

brain,  626 

breast,  762 

classification,  116 

giant-cell,  112 

jaw,  711 

joint,  545 

kidney,  103S      ■ 


INDEX 


1195 


Sarcoma,  liver,  997 
mixed-celled,  116 
prostate,  109S 
pure,  117 
round-celled,  116 
scalp,  597 
spindle-celled,  116 
tongue,  697 
tonsil,  714 
treatment,  118 
tubular,  116 
Scalds,  176 

Scalp,  birth-injuries,  595 
contusions,  595 
cyst,  dermoid,  597 
sebaceous,  597 
epithelioma,  597 
papilloma,  597 
sarcoma,  597 
surgical  affections,  595 
tumors,  597 
wound,  596 
Scapula,  congenital  elevation,  558 
dislocation,  430 
fracture,  367 
Schede's  operation,  thorax,  798 

veins,  275 
Schlatter's  disease,  413 
Schroeder's  operation,  cervix  uteri, 
Sciatica,  325 

Scirrhous  carcinoma,  127 
Scirrhus,  breast,  764 

acute,  767 
Sclavo's  serum,  87 
Scoliosis,  573 

treatment,  576 
Scrofula,  74 
Scrofuloderma,  295 
Scrotum,  dermoids,  1119 
elephantiasis,  1119 
epithelioma,  1119 
surgery,  1107 
tumors,  1119 
Scurvy,  461 
Sebaceous  cyst,  296 
Seborrheic  patch,  669 
Sedillot's  amputation,  232 
Semilunar  cartilage,  fracture,  448 

subluxation,  448     ' 
Semino-vesiculitis,  1110 
Senile  arthritis,  498 

gangrene,  58 
Senn's  amputation,  235 

powder,  178 
Sepsis,  36,  68 

postoperative,  187 
puerperal,  1152 
Septic  diarrhea,  857 
peritonitis,  856 
Septicemia,  68,  69 

puerperal,  1151 
Sequestrotomy,  475 
Sequestrum,  469 
Sero-serous  suture,  880 
Serum,  antitetanic,  199 
antitoxic,  44 


Serum,  Calmette's,  176 
gas  gangrene,  97 
Sclavo's,  87 
therapy,  44 
Shell  fragment  wounds,  194 
Shock,  181 

electric,  180 
erethistic,  183 
prevention,  184 
psychical,  184 
secondary,  187 
treatment,  184 
Short  circuiting  operation,  949 
Shoulder,  amputation,  227 
arthroplasty,  253 
birth  injuries,  556 
dislocation,  430 

congenital,  556 
excision,  513 
Sialo-lithiasis,  675 
Sigmoid  diverticulitis,  952 
hernia,  836 
surgery,  950 
tumors,  968 
Sigmoiditis,  952 
Sigmoidopexy,  965 
Sigmoidoproctostomy,  967 
Sigmoidoscope,  956 
3    Silicate  of  sodium  dressing,  141 
Silverfork  deformity,  388 
Simpson  splint,  intranasal,  666 
Sims's  position,  1122 
speculum,  1122 
Sinus,  47,  51 
frontal,  706 
lateral,  612 
longitudinal,  612 
sphenoidal,  707 
thrombosis,  621 
treatment,  51 

tuberculous,  treatment,  527 
Sinusitis,  chronic,  705 
frontal,  705 
maxillary,  705 
sphenoidal,  705 
Skey's  amputation,  230 
Skiagraphy  in  fractures,  335 
Skin,  surgery,  290 
Skin-grafting,  236 
autografts,  237 
Boykin's  method,  239 
homografts,  237 
Reverdin's  method,  237 
Thiersch's  method,  237 
Wolfe-Krause  method,  238 
Skull,  caries,  481 

congenital  malformations,  597 
dangerous  areas,  612 
fractures,  602 
base,  609 
newborn,  608 
vault,  604 
injuries,  602 
osteomyelitis,  611 
resection,  632 
trephining,  60S 


L196 


/  \ />/•:. v 


Skull,  wounds,  602 
Sliding  hernia,  836 
Sloughing,  57 

phagedena,  62 

ulcer,  53 
Small-shot  wounds,  197 
Smoker's  patches,  695 
Snake  bites,  174 

venom,  175 
Snapping  hip,  588 
Sounds,  urethral,  1070 
Spangaro's  incision,  208 

Spanish  windlass,  215 
Spasmodic  tic,  326 
Speculum,  bivalve,  1123 

examination,  1122 
Silence's  amputation,  227 
Spermatic  cord,  surgery,  1107 
Spermatocele,  1117 
Spermato-cystitis,  1110 
Sphacelus,  57 
Sphenoidal  sinus,  707 

sinusitis,  705 
Spina  bifida,  637 

ventosa,  113 
Spinal  anesthesia,  158 

canal,  hemorrhage,  639 

cord,  concussion,  639 
stab  wound,  640 
tumors,  664 

meningitis,  serous,  665 
tuberculous,  623 
Spine,  curvature,  lateral,  573 

dislocation,  640 

fractures,  640 

gunshot  wounds,  209 

infections,  662 

injuries,  639 

operation,  646 
treatment,  645 

sprain-fracture,  639 

static  disorders,  578 

strains,  639 

surgery,  (537 

tuberculosis,  649 

tumors,  664 
Spirocheta  pallida,  80 
Spleen,  abscess,  1009 

cysts,  1009 

dislocated,  1009 

gunshot  wounds,  899 

movable,  1009 

rupture,  894 

surgery,  1007 

syphilis,  1053 

tumors,  1007 
Splenectomy,  1011 

for  cirrhosis  of  liver,  996 
Splenic  anemia,  1010 
Splenomegaly,  1011 
Splints,  341 

Hodgen,  205 

Thomas,  204 
Spondylitis,  atrophic,  663 

deformans,  663 

hypertrophic,  664 


Spondylitis,  traumatic,  648 
typhoid,  662 

Spondylolisthesis,  579 

Spondylose  rhizomelique,  tiii I 
Sprain,  421 

Sprain-fracture,  331 

spine,  639 
Sprained  ankle,  421 
Sprengel's  deformity,  558 

incision,  984 
Squirrhe  en  cuirasse,  766 
Stab  wounds,  174 

abdomen,  896 
diaphragm,  sol 
spinal  cord,  040 
thorax,  783 
Stagnant  gall-bladder,  977 
Stamm's  gastrostomy,  929 
Staphylorrhaphy,  685 
Starch  dressing,  141 
Stasis  cyanosis,  776 
Status  lymphaticus,  188 
Steatoma,  296 
Steatorrhea,  1002 
Stenosis  of  cervix,  1126 
Sterilization,  142 
Sterno-clavicular  dislocation,  429 
Sternum,  fracture,  358 

tuberculosis,  781 
Still's  disease,  516 
Stokes's  amputation,  233 
Stomach,  carcinoma,  925 
treatment,  927 

cirrhosis,  925 

dilatation,  921 

gunshot  wounds,  898 

hour-glass,  917,  923 

operations,  928 

segmented,  923 

surgery,  916 

ulcer,  916 

hemorrhage,  920 
perforation,  919 
treatment,  918 
Stomatitis,  gangrenous,  63 
Strain,  421 

spine,  639 

tendon,  310 
Strangulated  hernia,  813 
Strangulation,  160 
Strapping  joints,  421 

ulcers,  55 
Stricture,  appendix,  902 

esophagus,  743 

rectum,  966 

urethra,  1074 
Strumitis,  736 
Stumps,  after-treatment,  223 

conical,  221 

diseases,  221 

dressing,  216 

end-bearing,  222 

structure,  221 
Subastragalar  amputation,  231 

arthrodesis,  571 

dislocation,  453 


INDEX 


1197 


Subcranial  abscess,  623 

hemorrhage,  619 
Subcuticular  suture,  166 
Subdeltoid  bursitis,  507 
Subinvolution,  uterus,  1143 
Subluxation,  elbow,  439 

jaw,  428 

semilunar  cartilage,  448 

wrist,  spontaneous,  585 
Submammary  abscess,  751 
Subpectoral  abscess,  778 
Subphrenic  abscess,  865 
Subscapular  abscess,  779 
Subungual  exostosis,  486 
Supernumerary  auricle,  677 

fingers,  547 

toes,  547 
Suppuration,  24 

without  bacteria,  27 
Suprapubic  cystotomy,  1025 

prostatectomy,  1093 
Suprascapular  abscess,  780 
Supravesical  hernia,  844 
Surgical  emphysema,  776 

infections,  74 

fever,  69 

kidney,  1030 

technique,  135 
Sutures,  162 

absorbable,  162 

Albert-Lembert,  881 

buried,  163 

chain,  163 

Connell's,  886 

continuous,  163 

Cushing's,  882 

Czerny's,  881 

deep,  163 

Dupuytren's,  882 

figure-of-eight,  164 

Gely's,  881 

Halsted's,  882 

hare-lip,  162 

interrupted,  162 

intestinal,  880 

knots,  166 

Lembert,  880 

lock-stitch,  163 

mattress,  163,  882 

Mayo's,  C.  H.,  889 

metal  clamps,  166 

nerve,  318 

non-absorbable,  162 

overhand,  163 

quilled,  163 

quilt,  163 

relaxation,  164 

sero-serous,  880 

splint,  164 

subcuticular,  166 

superficial,  163 

through-and-through,  880 

twisted,  162 

of  wounds,  165 
Syme's  amputation,  231 

urethrotomy,  1078 


Symmetrical  gangrene,  64 
Sympathectomy,  741 
Sympathetic  fever,  69 
Symptomatic  fever,  69 
Syndactylism,  547 
Synovitis,  503 

chronic  serous,  505 

knee,  505 
Syphilis,  80,  1044 

bone,  482 

breast,  753 

chancre,  81,  1045 

contagion,  1044 

diagnosis,  1056 

gumma,  1052 

hereditary,  1053 

treatment,  1060 

insontium,  1044 

joint,  545 

leptomeninges,  624 

pathology,  80 

secondary  lesions,  1048 

tertiary,  1051 

testicle,  1113 

tongue,  696 

treatment,  1057 

arsphenamin,  1060 

treponema  pallidum,  80 

Wassermann  test,  1057 
Syphilitic  bubo,  1047 

tubercle,  1051 
Syphiloderma,  81,  1049 
Syphiloma,  brain,  626 
Syringomyelia,  502 
Syringomyelocele,  637 


Talipes,  congenital,  558 

paralytic,  565 
Tapping  hydrocele,  1117 

lateral  ventricles,  600 
Tarsus,  dislocation,  452 

fracture,  419 

transverse  section,  571 

tuberculosis,  542 
Taxis,  818 
Taylor's  brace,  659 
Teale's  amputation,  232 
Telangiectases,  276 

Temporo-maxillary  joint  ankylosis,  709 
Tenderness,  abdominal,  859 

on  pressure,  34 
Tendon  transplants,  246 
Tendon-sheaths,  tuberculosis,  311 
Tendons,  dislocation,  310 

gunshot  wounds,  204 

rupture,  309 

strain,  3 10 

transplantation,  568 

wounds,  309 
Tenosynovitis,  310 
Tenotomy,  563 
Tension  pneumothorax,  787 
Terato-blastomas,  106 


1198 


INDEX 


Teratoma,  105 

ovary,  1158 
Terrier's  operation,  bile-duets,  986 
Tessier's  hernia,  846 
Testicle,  inflammation,  1108 

misplaced,  1107 

neuralgia,  1110 

non-descent,  1107 

surgery,  1107 

syphilis,  1053,  1113 

torsion,  1108 

tuberculosis,  1111 

tumors,  1114 

wandering,  1107 
Tetanus,  91 

antitoxin,  94 

cephalic,  94 

chronic,  94 

treatment,  94 
Textor's  amputation,  231 
Thecitis,  310 

Thiersch's  skin-grafting,  237 
Thigh,  amputation,  233 
Thomas  splint,  204 
Thoraco-laparotomy,  802 
Thoracoplasty,  798 
Thoracotomy,  792 
Thorax,  wounds,  bullet,  210 
gunshot,  209 
penetrating,  783 
shell  fragments,  210 
stab,  783 

operation,  785 
Thrombo-angeitis  obliterans,  58 
Thrombosis,  269 

arterial,  273 

mesenteric,  943 

sinus,  621 
Thrombus,  160,  269 
Thumb,  amputation,  226 

dislocation,  440 
Thymus  gland,  surgery,  741 
Thyro-glossal  cyst  and  fistula,  730 
Thyroid,  carcinoma,  741 

enlargement,  733 

surgery,  732 
Thyroidectomy,  740 
Thyroiditis,  732 
Thyrotomy,  721 
Thyrotoxicosis,  737 
Tibia,  fracture  of,  412 
Tibio-tarsal  dislocation,  451 
Tic  convulsif,  326 

douloureux,  322 

spasmodic,  326 
Toe,  supernumerary,  547 
Toe-nail,  ingrowing,  291 
Tongue,  abscess,  695 

carcinoma,  697 
operation,  700 

chancre,  696 

excision,  704 

gumma,  696 

ichthyosis,  695 

sarcoma,  697 

surgery,  692 


Tongue,  syphilis,  695 

tuberculosis,  696 
Tongue-tie,  692 
Tonsil,  carcinoma,  714 

sarcoma,  714 

surgery,  713 
Tooth  wounds,  174 
Torsion  of  arteries,  261 
Torticollis,  579 

spasmodic,  326,  580 
Tourniquet,  214 
Toxemia,  69 
Toxic  nephritis,  1028 
Toxic  peritonitis,  856 
Toxins,  bacterial,  19 
Tracheoplasty,  1138 
Trachelorrhaphy,  1138 
Tracheotomy,  719 

tube,  720 
Transduodenal  choledochotomy,  989 
Transfusion  of  blood,  147 
Transplant,  bone,  248 

cartilage,  247 

fascia,  246 

fat,  246 

free,  245 

GiUies's,  243 

tendon,  246 
Traube-Hering  waves,  617 
Traumatic  asphyxia,  776 

delirium,  183 

treatment,  185 

fever,  69 

gangrene,  88 

spontaneous  emphysema,  88 
Traumatopnea,  783 
Trench  feet,  180 
Trephine,  Gait's,  608 

Hudson's,  633 
Trephining,  skull,  608 
Treponema  pallidum,  80 
Trichiniasis,  308 
Trident  hand,  455 
Trifacial  neuralgia,  322 
Trigger  finger,  586 
Truss,  810 

cross-body,  837 

Hood,  838 
Tubal  abortion,  1148 
Tubercle,  anatomical,  74 

syphilitic,  1051 
Tuberculin,  75 

old,  79 

test,  79 
Tuberculoma,  brain,  626 
Tuberculosis,  74 

ankle,  542 

appendix,  915 

bladder,  1020 

bone,  479 

breast,  753 

carpus,  544 

costal  cartilages,  780 

cutis,  294 

diagnosis,  78 

elbow,  543 


INDEX 


1199 


Tuberculosis,  glands,  neck,  724 

hernial  sac,  867 

hip,  530 

joint,  519 

kidney,  1036 

knee,  541 

lungs,  799 

lymph  nodes,  300,  725 

meninges,  623 

parotid,.  672 

pathology,  75 

peritoneum,  866 

v.  Pirquet's  test,  79 

pleura,  798 

ribs,  780 

sacro-iliac,  544 

salivary  glands,  672 

skin,  294 

spine,  649 

sternum,  781 

tarsus,  542 

tendon  sheaths,  311 

testicle,  1111 

tongue,  696 

treatment,  80 

tuberculin  test,  79 

vertebrae,  649 

wrist,  544 
Tuberculous  arthritis,  operation,  527 

dactylitis,  481 

gumma,  76 

rheumatism,  517 

sinus,  treatment,  527 
Tubo-ovarian  abscess,  1134 

cysts,  1155 
Tubular  aneurysm,  280 
Tufnell's  treatment,  aneurysm,  284 
Tumors,  101 

abdominal,  diagnosis  of,  1007 

adenocarcinoma,  126 

adenoma,  120 

alveolus,  710 

appendix,  915 

bladder,  1021 

blast  oma,  106 

bone,  485 

brain,  626 

treatment,  630 

breast,  754 

benign,  759 
malignant,  762 

capsule,  102 

carcinoma,  121 
glandular,  126 

carotid  gland,  729 

cartilage,  110 

cheloid,  109 

chloroma,  114 

cholesteatoma,  130 

chondroma,  110 

chondrosarcoma,  117 

chordoma,  115 

classification,  104 

consistency,  102 

cord,  spinal,  664 

cylindroma,}  130 


Tumors,  cyst  formation,  130 
parasitic,  132         «^ 

cystadeno-carcinoma,  126 

cystadenoma,  120 

cystoma,  131 

definition,  101 

desmoids,  309 

embryoma,  106 

endosteoma,  111 

endothelioma,  129 

enosteoma,  111 

epithelioma,  123 

epulis,  710 

excision,  132 

exostosis,  111 

fibroadenoma,  120 

fibroid,  uterine,  1160 
recurrent,  116 

fibroma,  108 

fibromyxoma,  109 

fibrosarcoma,  117 

form,  101 

formation,  Cohnheim's  theory,  103 
parasitic  theory,  104 
Ribbert's  theory,  104 

gall-bladder,  997 

glioma,  115 

gliosarcoma,  117 

hemangeio-endothelioma,  130 

hylic,  106 

hypernephroma,  129 

intestinal,  948 

intraspinal,  664 

irritable,  of  breast,  751 

jaw,  710 

joint,  545 

keloid,  109 

kidney,  1038 

larynx,  717 

leiomyoma,  115 

lepidic,  106 

lepidoma,  transitional,  128 

lipoma,  107 

liver,  996 

lung,  801 

lymphangeio-endothelioma,  130 

lymphoma,  115 

lymphosarcoma,  117 

malignancy,  102 

mediastinal,  782 

melanoma,  130 

mesothelioma,  129 

metastasis,  103 

mixed,  106 

muscle,  309 

myeloma,  112 

myoma,  115 

sarcomatodes,  117 

myosarcoma,  117 

myxolipoma,  107 

myxoma,  109 

myxosarcoma,  109 

naso-pharynx,  715 

nerve,  326 

neurinoma,  326 

neuroma,  115 


1200 


INDEX 


Tumors,  odontoma,  112 

osteoma,  1 1 1 
osteosarcoma,  117 
ovary,  1154 

pancreas,   1001 

papilloma,  119 
parotid,  672 
periductal,  759 
perithelioma,  130 
pleura,  S01 
prostate,  1097 
psammoma,  130 
rate  of  growth,  102 
rectum,  968 
recurrence,  103 
rhabdomyoma,  115 
sarcoma,  115 
scalp,  597 
scrotum,  1119 
sigmoid,  968 
spinal,  664 
spleen,  1007 
stomach,  925 
terato-blastoma,  106 
teratoma,  105 
testicle,  1114 
thyroid,  741 
xanthoma,  107 

Twisted  suture,  162 

Tyloma,  290 

Typhoid  arthritis,  514 
carriers,  983 
hemorrhage,  945 
perforation,  944 
periosteitis,  467 
spine,  662 
spondylitis,  662 


Ulcer,  52 

callous,  54 

duodenum,  916 
chronic,  917 
hemorrhage,  920 
perforation,  919 
treatment,  918 

edematous,  53 

gastric,  916 

gastro-jejunal,  933 

healthy,  53 

indolent,  54 

inflamed,  53 

irritable,  53 

Jacob's,  124 

jejunum,  peptic,  933 

leg,  55 

syphilitic,  56 

Marjolin,  57 

neuralgic,  53 

perforating,  291 

phagedenic,  53 

repair,  52 

rodent,  124,  670 

rose,  766 


I  leer,  simple,  53 

skin-grafting,  56 
sloughing,  53 
stomach,  916 

acute,  917 

chronic,  917 

hemorrhage,  920 

perforation,  919 

treatment,  918 

strapping,  55 

varicose,  57 

warty,  57 

weak,  53 
Ulceration,  26,  52 
Ulcus  molle,  1060 
Ulna,  dislocation,  438 

fracture,  385 
Umbilical  fistula,  944 

hernia,  826 

strangulated,  830 
Union  by  first  intention,  161 

in  fractures,  336 
Urachal  cysts,  1017 

fistula?,  1017 
Ureter,  catheterization,  1016 
Ureteral  calculus,  1035 
Ureterolithotomy,  1036 
Ureteroplasty,  1031 
Urethra,  foreign  bodies,  1071 

prolapse,  1074 

rupture,  1072 

stricture,  1074 

treatment,  1076 

surgery,  1070 
Urethral  fever,  1080 
Urethritis,  gonococcic,  1065 

in  female,  1128 

non-gonococcic,  1074 
Urethrotome,  1078 
Urethrotomy,  1077 

perineal,  1079 
Urinary  disorders,  diagnosis,  1013 

extravasation,  1073 

fever,  1080 

fistula,  1082 
Urine,  residual,  1071 

retention,  1070 
Uterus,  adenomyoma,  1163 

anteflexion,  1143 

carcinoma,  1167 

chorio-epithelioma,  1169 

displacements,  1143 

fibroids,  1160 

fibromyoma,  1160 

hysteropexy,  1143 

malformation,  1127 

myoma,  1160 

perforation,  1151 

polypus,  1162 

procidentia,  1145 

prolapse,  1145 

retroflexion,  1143 

retroversion,  1143 

subinvolution,  1143 

ventro-fixation,  1144 

ventro-suspension,  1 144 


INDEX 


1201 


Vaccination,  145 
Vaccins,  44 

in  inflammation,  44 
Vagina,  absence,  1126 
Vaginal  examination,  1122 
hernia,  851 
hysterectomy,  1166 
puncture,  1154 
Vaginitis,  1128 
Vagus  pulse,  618 
Valgus,  paralytic,  568 
Valsalva's  treatment  for  aneurysm,  287 
Varicocele,  1118 

lymphatic,  300 
Varicose  aneurysm,  267 
ulcer,  57 
veins,  274 
Varix,  274 

Vein,  jugular,  resection  of,  622 
Veins,  entrance  of  air,  266 
Venereal  diseases,  1044 

wart  prevention,  1066 
Venesection,  39 
Venous  aneurysm,  265 

nevi,  277 
Ventral  hernia,  823 
Ventricles,  tapping,  600 
Ventro-suspension  of  uterus,  1114 
Verruca,  290 

Verrucse  acuminata3,  1105 
Vertebra,  dislocation,  640 
fracture,  640 
osteitis,  648 
osteomyelitis,  648 
tuberculosis,  649 
Vertebral  column,  dystrophies,  663 
Vesical  calculus,  1021 
Vicious  circle,  931 
Visceroptosis,  953 
Volkmann's  contracture,  583 
Volvulus,  938 
Vulva,  carcinoma,  1170 

imperforate,  1125 
Vulvitis,  1128 
Vulvo-vaginal  abscess,  1128 


W 


"Wardrop's  ligation,  286 
War  hospital,  190 
Wart,  290 

venereal,  290,  1066 
Warty  ulcer,  57 
Wassermann  test,  1057 
Wax.  Horsley's,  632 

Mosetig-Moorhof's,  478 
Weaver's  bottom,  298 
Webbed  fingers,  547 
Wen,  296 

Whitehead's  operation,  hemorrhoids,  963 
tongue,  704 

varnish,  684 
White  swelling,  522 


Whitlow,  311 
Wille's  test,  1003 
Wiring  aneurysm,  287 
Witzel's  gastrostomy,  929 
Wolfe-Krause  skin-grafting,  238 
Wool-sorter's  disease,  85 
Wounded,  evacuation,  191 
Wounds,  160 

abdominal,  suture,  881 

arrow,  174 

art erio- venous,  267 

bavonet,  174 

bites,  174 

blank  cartridge,  198 

bloodvessels,  266 

bullet,  194 

bursa?,  297 

chemical  sterilization,  169 

contused,  166 

debridement,  201 

drainage,  165 

dressing,  166 

gunshot,  190 

abdomen,  211,  897 
bloodvessels,  203 
bones,  204 
diaphragm,  802 
drainage,  202 
dressing,  202 
duodenum,  898 
general  nature,  193 
head,  208 
intestine,  897 
joints,  206 
kidnev,  1039 
liver,  898 
lung,  209 
missiles,  192 
nature,  193 
nerves,  204 
pancreas,  899 
spine,  209 
spleen,  899 
stomach,  898 
suture,  202 
tendon,  204 
thorax,  209 
treatment,  199 
of  heart,  268 
incised,  160 

dressing,  166 
healing,  161 
treatment,  162 
union,  161 
infected,  169 
intestinal,  suture,  881 
joint,  422 
lacerated,  166 
muscle,  304 
neck,  722 
nerve,  317 
poisoned,  174 
punctured,  173 
scalp,  596 

septic,  Carrel-Dakin  treatment,  170 
shell  fragments,  196 


1202 


IXDEX 


Wounds  of  skull,  602 
small  shot,  197 
stab,  174 

abdomen,  896 

diaphragm,  sol 

kidney,  1039 

spinal  cord,  640 

thorax,  783 
suture,  165 
tendons,  309 
thorax,  bullet,  210 

penetrating,  r83 

shell  fragments,  210 
tooth,  171 
unbridling,  201 
Wrist,  arthroplasty,  253 
dislocation,  440 
excision,  513 
subluxation,  spontaneous,  585 


Wrist,  tuberculosis,  544 
Wrist-joint  amputation,  226 
Wry-neck,  579 
Wyeth's  hemostasis,  227,  233 


Xanthoma,  107 
Xiphodynia,  359 
X-ray  dermatitis,  180 
in  fractures,  "35 
therapeutic  uses,  181 


Zygoma,  fracture,  356 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28I239IM100 

COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

Rd  31  As3  1920  C.I 

Surgery;  its  pnncip 


2002104466 


RD31 

Ashhurst 


Aso 
1920 


